Form G-App-36010 Vt - Life Insurance Application Form - Group Term Life Insurance
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1
2A
F
L
95
pplicAtion
orm For
ife to
G
t
l
i
roup
erm
iFe
nsurAnce
Underwritten by The United States
Life Insurance Company in the City of
New York (Herein called the Company)
Applicant
OLA
_ ______ ___ __ ___ _ __ ____ _____ ______ _____ ___ ___ _____ ___ __ __ _ __ __ _ __ __ __ _ __ __ _ __ __ _ __ __ _ __ __ _ __ __ __ _ __ __ _ __ __ _ __ __ __ _ _ ___ ____ ___ ___ ___ ___ ____ ___ ___ ____ ___ _
Title (Dr. / Mr. / Mrs. / Ms.), First Name, Middle Initial, Last Name
_ ______ ___ __ ___ _ __ ____ _____ ______ _____ ___ ___ _____ ___ __ __ _ __ __ _ __ __ __ _ __ __ _ __ __ _ __ __ _ __ __ _ __ __ __ _ __ __ _ __ __ _ __ __ __ _ _ ___ ____ ___ ___ ___ ___ ____ ___ ___ ____ ___ _ __ ____ ___ ___ ____ ___ ___ ____ ___ ____ ___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Mailing Address
Home Phone
_ ______ ___ __ ___ _ __ ____ _____ ______ _____ ___ ___ _____ ___ __ __ _ __ __ _ __ __ __ _ __ __ _ __ __ _ __ __ _ __ __ _ __ __ __ _ __ __ _ __ __ _ __ __ __ _ _ ___ ____ ___ ___ ___ ___ ____ ___ ___ ____ ___ _ ____________________________________
City
State
Zip Code
Work Phone
_ ______ ___ __ ___ _ __ ____ _____ ______ _____ ___ ___ _____ ___ _ _ __ __ _ __ __ _ __ __ __ _ __ __ _ __ __ _ __ __ _ __ __ __ _ __ __ _ __ __ _ __ __ _ __ ___ ___ ___ ____ ___ ___ ____ ___ ____ ___ ___ __ __ ____ ___ ___ ____ ___ ___ ____ ___ ____ ___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Social Security #
Email
Cell Phone
Birth Date_____________ Location of Birth ________________ Gender_______ Occupation_________________________________________________
MM/DD/YYYY
M / F
My eligibility status is (check one): q Alumnus/a q Student q Eligible Family Member
If Eligible Family Member (check one):
q Spouse q Domestic Partner
Sponsoring college, university, school, or alumni/ae association: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Insurance Amount Requested. (Refer to brochure for eligibility, insurance amounts, and coverage description.) I request:
A.
q $100,000 q $75,000 q $50,000 q $25,000 q Other $ _____________ Amounts must be in $1,000 increments; minimum $10,000; maximum $100,000.
B.
Health Information. Please complete all questions below. In this section, “you” and “your” refers to the person for whom insurance is being requested.
Name and Address of Applicant’s Physician _______________________________________________________________________________________
1.
Height __________Ft __________In
Weight __________ Lbs.
Yes No
2.
Have you ever had, been diagnosed with, or been treated for: chest pain; disease or disorder of the heart, liver, kidneys, blood, or lungs;
high blood pressure; stroke or other neurological disorder; mental/nervous disorder; drug or alcohol abuse; diabetes; cancer or tumor;
or diagnosed by a licensed physician for Acquired Immune Deficiency Syndrome (AIDS), or AIDS Related Complex (ARC)?
_______
q
q
3.
Have you during the past 5 years, consulted any physician or other practitioner or been confined or treated in any hospital or similar
institution, for any reason other than those stated above?
_ _ __ __ _ __ __ _ __ __ _ __ __ _ __ ___ ___ ___ ____ ___ ___ ____ ___ ___ ____ ___ ____ ___ ___ ____ ___ ___ ____ ___ ___ ____ ___ ___ ___ _ _ _ _
q
q
4.
Are you now taking prescription medication or receiving medical attention?
____________________________________________
q
q
For “Yes” answers to questions 2-4 above, please provide details in the space provided below. If more space is needed, use a separate sheet of paper
signed and dated. If additional information is attached, check this box. q
Name and Address of
Question #
Condition
Date Occurred
Duration
Degree of Recovery
Physicians, Hospitals,
or Clinics Consulted
G-APP-36010 VT(R1/08)
Group Policy No. G-610,477 6/17-VT
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