National Guardian Life Insurance Company (Page 2 of 4) in pdf

Applicant's Statements and Agreements

I understand that the effective date of the policy will be the date recorded in the Policy Schedule.

I understand the policy I am applying for contains different Waiting Periods for certain benefits listed in the Policy Schedule of

Benefits. This means that no benefits are payable during the listed Waiting Period. The Waiting Period begins on the effective date

of coverage.

I understand that dependent children, if any, will be covered until the end of the month following their 19th birthday (24 if full-time

students).

I understand that: (a) National Guardian Life Insurance Company is not bound by any statement made by me, the applicant, or any

associate/agent of National Guardian Life Insurance Company unless written herein. (b) The associate/agent cannot change the

provisions of the policy or waive any of its provisions either orally or in writing. (c) The policy together with this application,

endorsements, benefit agreements and riders, if any, is the entire contract of insurance. (d) No change to the policy will be valid until

approved by Our president and secretary, and noted in or attached to the policy.

Notice of Information Practices

To issue an insurance policy, We may need to obtain additional information about You and any other persons proposed for insurance.

Some information will come from You and some may come from other sources. That information and any other subsequent information

collected by Us may in some circumstances be disclosed to third parties without Your specific consent. You have the right to access and

correct the information collected about You except information that relates to a claim or to a civil or criminal proceeding. If You wish to

have a more detailed explanation of Our information practices, please submit a written request to Us.

Authorization to Obtain Information

I authorize the following to give information (defined below) to National Guardian Life Insurance Company or any person or group acting

on their part: any medical professional, any medical care institution, insurer, reinsurer, government agency, consumer reporting agency or

employer. "Information" means facts of a medical nature in regard to my physical or mental condition, employment, or other insurance

coverage, or any other nonmedical facts. I understand that this information will be used by National Guardian Life Insurance Company to

determine eligibility for insurance and may be used to evaluate a claim for benefits during the time it is valid. I agree that this

authorization is valid for 26 months from the date signed. I know that I have a right to receive a copy of this authorization upon request. I

agree that a copy of this authorization is as valid as the original.

Please Note: This Authorization excludes the release of information about HIV (AIDS Virus) tests which were administered: (1) to a

criminal offender or crime victim as a result of a crime that was reported to the police; (2) to a patient who received the services of

emergency medical services personnel at a hospital or medical care facility; (3) to emergency medical personnel who were tested as a

result of performing emergency medical services. The term "emergency medical personnel" includes individuals employed to provide

pre-hospital emergency services; licensed police officers, firefighters, paramedics, emergency medical technicians, licensed nurses, rescue

squad personnel, or other individuals who serve as volunteers of an ambulance service who provide emergency medical care; and other

persons who render emergency care or assistance at the scene of an emergency, or while an injured person is being transported to receive

medical care and who would qualify for immunity under the good Samaritan law.

I understand that the premium amount listed on this application represents the premium amount that either my employer will remit to

National Guardian Life Insurance Company on my behalf, or I will remit directly to them. I further understand that this amount, because

of my employer's billing/payroll practices, may differ from the amount being deducted from my paycheck or the premium amount quoted

to me by my associate/agent.

I also understand that if I am receiving any Medicaid benefits, the purchase of this coverage may not be necessary.

If I am applying to replace existing coverage with this policy, I acknowledge that the policies may have different benefits and that I should

make a comparison to personally determine which is best for me. I understand and agree that I am terminating my current policy and its

benefits for the benefits provided in the National Guardian Life Insurance Company Policy.

that

I have read, or had read to me, the completed application, and I realize policy issuance is based upon statements and answers provided herein, and

any missing and/or inaccurate information or fraudulent statement in the application that materially affects the Company’s acceptance of

the risk assumed may result in loss of coverage under the policy.

WARNING: Any person who knowingly and with intent to defraud any insurance company or other person submits an application for

insurance containing a any materially false information or conceals, for purpose of misleading, information concerning any fact material

thereto, commits a fraudulent insurance act, which is a crime and may subject such person to criminal and civil penalties.

Signed and Dated at ______________________________________________________ on ______________________________

City and State

Date

Applicant’s Signature ______________________________________________________________________________________

Associate/Agent’s Signature______________________________________________ Date____________________________________

Licensed Resident Associate/Agent

NDNIND2005 APP-MN

version 3.0

National Guardian Life Insurance Company Page 2

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