Important Notice: Replacement of
Attention: Replacement Section
You are herewith given notice that we are in receipt of application(s) for life insurance or annuity(ies) for an individual presently insured with your company.
This notice is given pursuant to 50 III. Adm. Code 917.70(c).
IP-RPL-IL-EXB-0422-V1 Page 1 of 1
Insurance or Annuities 4254 Saw Mill Run Blvd., Pittsburgh, PA 15227
B
BE PRESENTED TO, SIGNED AND DATED BY THE OWNER AND PRODUCER AT THE TIME OF APPLICATION
of Existing Insurer Address
Life
EXHIBIT
MUST
Name
Insured Address Contract # Agreements and Signatures
Owner’s Signature Date Producer’s Signature Date Phone: 412-884-5100 | 800-765-4428 | newbusiness@gbu.org | gbu.org