YOUTH 3 PAY MEMBERSHIP INDIVIDUAL LIFE INSURANCE APPLICATION 1. Proposed Insured
Legal Name (First, Middle Initial, Last)
Phone
Address (Street, City, State, Zip) Place of Birth (State/Country)
Social Security Number
Birth Date
Age
Gender
Is Proposed Insured a current member of GBU Financial Life?
Yes
Male
Female No
Preferred District
2. Owner
Legal Name (First, Middle Initial, Last) Address (Street, City, State, Zip) Email
Phone
Social Security Number
Birth Date
Relationship to Proposed Insured
3. Payor
Legal Name (First, Middle Initial, Last) Address (Street, City, State, Zip) Email
Phone
Social Security Number
Birth Date
Relationship to Insured
4. Additional Contact Information
Person to contact about policy if Proposed Insured, Payor or Owner cannot be located. Legal Name (First, Middle Initial, Last) Address (Street, City, State, Zip) Email
Phone
Relationship to Proposed Insured
5. Insurance Applied For
YOUTH 3 PAY LIFE Face Amount (check one): $5,000 MEMBERSHIP POLICY ✔ $3,000
$10,000
Annual Premium Amount: $
Amount Paid with Application: $
6. Dividend Cash Option 7. Beneficiary(ies) Primary Beneficiary(ies)
Premium Reduction
Paid-Up Additions
Accumulate at Interest
Legal Name (First, Middle Initial, Last) Address (Street, City, State, Zip) Social Security Number Relationship to Proposed Insured
Share %
Legal Name (First, Middle Initial, Last) Address (Street, City, State, Zip) Social Security Number Relationship to Proposed Insured
Share %
GBU FINANCIAL LIFE
ICC19-Mem3PayAPP
www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428
Page 1 of 6
YOUTH 3 PAY LIFE MEMBERSHIP INDIVIDUAL LIFE INSURANCE APPLICATION
7. Beneficiary(ies) Contingent Beneficiary(ies) (continued)
Legal Name (First, Middle Initial, Last) Address (Street, City, State, Zip) Social Security Number Relationship to Proposed Insured
Share %
Legal Name (First, Middle Initial, Last) Address (Street, City, State, Zip) Social Security Number Relationship to Proposed Insured
8. Active or Pending Insurance Policies
Share %
Note: If additional space is needed, list on a separate sheet of paper. Include the Policy Owner’s signature and date.
List active or pending life insurance policies of Proposed Insured. (If none, so indicate.) Date of Issue or Pending Application
Name of Company
Life Amount $
Replacement Yes
No
Yes
No
Will this contract replace an existing insurance policy?
Yes
No
If yes, have you submitted the appropriate replacement forms?
Yes
No
$
9. Health
Accidental Death Benefit Amount $ $
For Proposed Insured Height
Weight
Primary Medical Provider’s Phone
Primary Medical Care Provider Name Address (Street, City, State, Zip) Date and reason of last visit
10. Additional Details
What treatment was given? Or medication prescribed? Was the Proposed Insured born prematurely or with abnormalities at birth diagnosed by a Yes No medical professional? Has the Proposed Insured been treated or diagnosed by a medical professional for a respiratory disorder, heart disease or disorder, kidney or liver disease, diabetes, mental disease or disorder Yes No or cancer? Please provide additional details on: Illness or Injury, Dates, Names and Addresses of Doctors/Hospitals and Degree of Recovery
11. Details, Remarks or Special Requests
GBU FINANCIAL LIFE
ICC19-Mem3PayAPP
www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428
Page 2 of 6
AGREEMENT – AUTHORIZATION – ACKNOWLEDGEMENT
This authorization complies with the HIPAA Privacy rule.
I understand I may revoke this authorization at any time, except to the extent that action has been taken in reliance on this authorization. Written notice must be sent to GBU Financial Life, 4254 Saw Mill Run Boulevard, Pittsburgh, PA 15227-3394. I, the Parent/Guardian of the Proposed Insured (and any Payor or Owner signing below), by my signature set forth hereafter AGREE to the following: a) All statements and answers in this application are complete and true to the best of my knowledge and belief. b) Except as stated in the Conditional Receipt, no insurance will take effect unless the first full premium is paid and policy is delivered while the health of any Proposed Insured continues, without any material change, to be as represented in this application. c) No agent has authority to waive any answer; otherwise modify this application; or bind GBU Financial Life, hereinafter called “Company” in any way by making any promise or representation which is not set out in writing in this application. d) $ has been deposited toward payment of the first premium on the policy. The terms of the Conditional Receipt received for that premium deposit are accepted. I AUTHORIZE any physician; medical practitioner; hospital; clinic; other medical or medically related facility; to give the Company or its reinsurer(s) all information it holds that pertains to medical consultations; treatments; surgeries; and hospital confinements which relate to the physical and mental condition of myself or my minor children. This authorization also includes a pharmacy benefits manager; insurance support organization; pharmacy/government agency; insurance or reinsuring company; MIB, Inc (“MIB”); consumer reporting agency; or any other organization; institution; or person. This authorization also includes information about drugs and alcoholism or any other nonhealth (non-medical) history information. I authorize the Company or its reinsurers to release any information including my physical health information obtained to reinsuring companies; MIB; or other persons or organizations performing business or legal service in connection with my application or claim. I further authorize the Company and its reinsurers to release any information that may be otherwise lawfully required or as I may further authorize. As to this authorization, I agree that a photographic copy will be valid as the original and that it will be valid for 24 months from the date shown below. This time limit is permitted by applicable law in the state where the policy is delivered or issued for delivery. I know examiners, reinsurers, attorneys or other medical director may disclose such health information for purposes of underwriting, compliance, record clarification or explanation. The aforementioned parties may also disclose such information in response to litigation, summons or subpoenas. I understand that after this information is disclosed the recipient may re-disclose it resulting in loss of protection by federal regulations. I understand that there are limitations on my right to revoke this authorization. Any action taken in reliance on this authorization will be valid if such action has been taken prior to receipt of notice of revocation. If this authorization is used to collect information in connection with a claim for benefits, it will be valid for the duration of the claim. If the law of my state so provides, my authorization may not be revoked during a contestable investigation. I also understand that my revocation of this authorization will not result in the deletion of codes in the MIB databases if such codes are reported by the Company or its reinsurers (or the Company or its reinsurers becomes obligated to report such codes to MIB) while this authorization is in force. I may refuse to sign this authorization and that my refusal to sign will affect my ability to obtain life insurance coverage. ACKNOWLEDGE receipt of the following notices: a) “Notice of Information Practices” required by Public Law 91-508 and other information practices, statutes, and b) Notification regarding MIB, Inc.
GBU FINANCIAL LIFE
ICC19-Mem3PayAPP
www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428
Page 3 of 6
AGREEMENT – AUTHORIZATION – ACKNOWLEDGEMENT (CONTINUED)
I (We) declare that the Proposed Insured desires to unite with GBU members for the following reasons. (a) Financial security and fraternal benefits. (b) Charitable community involvement. (c) Share the appreciation of our members’ culture and heritage. (d) Meet any other requirements for membership established by GBU. By purchasing an insurance product from GBU Financial Life, the Proposed Insured gains automatic membership in the society including all of its rights and privileges. GBU Financial Life is licensed to do business in this state. As a not-for-profit organization, fraternal benefit societies are not included in the State Guaranty Association. This means that fraternal benefit societies cannot be assessed for the insolvency of other life insurers or other fraternal benefit societies. By law a fraternal benefit society is responsible for its own solvency. If there is an impairment of reserves, a certificate holder may be assessed a proportionate share of the impairment. This process is described in the certificate issued by the society. Fraud Warning. Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under the state law.
Dated at ______
City
_____________, ____
State
_____, on __________________________, 20
.
_
________________________________________ Printed Name of Parent or Guardian
____________________________________________ Signature of Parent or Guardian
_
________________________________________ Printed Name of Owner (if other than Parent or Guardian)
____________________________________________ Signature of Owner (if other than Parent or Guardian)
_
________________________________________ Printed Name of Payor (if other than Owner)
____________________________________________ Signature of Payor (if other than Owner)
_
____________________________________________ Signature of Licensed Agent
________________________________________ Printed Name of Licensed Agent
_ ______________________________________ Licensed Agent Number
GBU FINANCIAL LIFE
ICC19-Mem3PayAPP
www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428
Page 4 of 6
CONDITIONAL RECEIPT
Terms and Conditions: Coverage is issued bearing the date of this receipt will become effective on the date of the application or last medical examination, whichever is later. Coverage will be provided when the following conditions are met: 1. The application and required information are received at the GBU Financial Life Home Office. 2. All persons proposed for coverage are insurable at standard rates exactly as applied for according to the rules and practices of GBU Financial Life. 3. The full first premium is paid in cash on the date of application. The maximum amount of life insurance effective under this receipt cannot exceed $100,000. This includes accidental death and pending insurance. There will be no conditional insurance coverage, if all conditions are not met. GBU Financial Life’s liability will be limited to returning any premium submitted to GBU Financial Life with this receipt. Returning submitted premiums and this receipt are necessary if any of the following occurs: a) one or more of the receipt’s conditions have not been met exactly; or b) any Proposed Insured dies by suicide. If the Policy is not issued exactly as applied for, it will become effective when it is delivered to and accepted by the applicant and the modal premium is paid. If the application is declined or not approved within 60 days of its completion; no insurance will have been in force. Any premium paid will be returned. No agent of GBU Financial Life has the authority to change or modify any of the provisions in this receipt. GBU FINANCIAL LIFE Plan Youth 3 Pay Life Membership Life Insurance
Amount Received $
ALL PREMIUM CHECKS MUST BE PAYABLE TO GBU FINANCIAL LIFE. DO NOT MAKE THE CHECK PAYABLE TO THE AGENT OR LEAVE THE PAYEE BLANK.
By ________________________________________________________ Signature of Agent
Date ________________________
------------------------------------------------------------------------------------------------------------------------------------------------------------------
GBU FINANCIAL LIFE
ICC19-Mem3PayAPP
www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428
Page 5 of 6
INVESTIGATIVE CONSUMER REPORTS
Under Public Law 91-508, we are required to inform persons proposed for insurance that, as part of our regular underwriting procedure, an investigative consumer report may be obtained which will provide applicable information concerning character, general reputation, personal characteristics, and mode of living. This information will be obtained through personal interviews with your friends, neighbors, and associates.
IMPORTANT NOTICE
The underwriting process (evaluation and classification of risks) is necessary to assure reasonable cost of insurance and provide a mechanism by which policyholders pay their fair share of the cost. In considering your application, information from various sources is considered, including your own statements, the results of your physical examination (if required), and any reports we obtain from doctors or medical facilities where you have been treated. NOTIFICATION REGARDING MIB, Inc. (“MIB”): Information regarding your insurability will be treated as confidential. GBU Financial Life or its reinsurers may, however, make a brief report thereon to the MIB. The MIB is a not-for-profit membership organization of insurance companies operating an information exchange on behalf of its members. The MIB may also release information in your file to another MIB-member company to whom application may be made for life or health insurance coverage; or, a benefit claim is submitted. Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your file. Please contact the MIB at [866-692-6901]. If you question the accuracy of information in MIB’s file; you may contact MIB and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. MIB’s information office address: 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734. GBU Financial Life or its reinsurers may also release information in its file to other insurance companies to whom you may apply for life or health insurance; or, to whom a claim for benefits may be submitted. Information for consumers about the MIB may be obtained at its website www.mib.com. THIS NOTIFICATION MUST BE GIVEN TO THE PROPOSED INSURED BEFORE THE APPLICATION IS COMPLETED.
GBU FINANCIAL LIFE
ICC19-Mem3PayAPP
www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428
Page 6 of 6
IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR ANNUITIES
You are contemplating the purchase of a life insurance policy or annuity contract. In some cases this purchase may involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed purchases are also considered replacements. A replacement occurs when a new policy or contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing policy or contract, or an existing policy or contract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase. A financed purchase occurs when the purchase of a new life insurance policy involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing policy, to pay all or part of any premium or payment due on the new policy. A financed purchase is a replacement. You should carefully consider whether a replacement is in your best interest. You will pay acquisition costs and there may be surrender costs deducted from your policy or contract. You may be able to make changes to your existing policy or contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy and may reduce the amount paid upon the death of the insured. We want you to understand the effects of replacements before you make your purchase decision and ask that you answer the following questions and consider the questions on the back of this form.
Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract?
Yes
No
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Yes
No
If you answered “yes” to either of the above questions, list each existing policy or contract you are contemplating replacing (include the name of the insurer, the insured or annuitant, and the policy or contract number if available) and whether each policy or contract will be replaced or used as a source of financing.
Insurer Name
Contract or Policy # Insured or Annuitant
Replaced (R) or Financed (F)
Make sure you know the facts. Contact your existing company or its agent for information about the old policy or contract. If you request one, an in-force illustration, policy summary or available disclosure documents must be sent to you by the existing insurer. Ask for and retain all sales material used by the agent in the sales presentation. Be sure that you are making an informed decision. The existing policy(ies) or annuity contract (s) is/are being considered for replacement because:
I certify that the responses herein are, to the best of my knowledge, Applicant’s Signature Applicant’s Printed Name
Date
Producer’s Signature
Date
Producer’s Printed Name
GBU FINANCIAL LIFE
*%8 1$,& 53/ )orP-0622V3
newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257
1 of 2
I do not want this notice read aloud to me. __________ (Applicants must initial only if they do not want the notice read aloud.) A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison of the costs and benefits or your existing policy or contract and the proposed policy or contract. One way to do this is to ask the company or agent that sold you your existing policy or contract to provide you with information concerning your existing policy or contract. This may include an illustration of how your existing policy or contract is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare policies or contracts. You should discuss the following with your agent to determine whether replacement or financing your purchase makes sense: PREMIUMS: x Are they affordable? x Could they change? x You’re older—are premiums higher for the proposed new policy? x How long will you have to pay premiums on the new policy? On the old policy? POLICY VALUES: x New policies usually take longer to build cash values and to pay dividends. x Acquisition costs for the old policy may have been paid; you will incur costs for the new one. x What surrender charges do the policies have? x What expense and sales charges will you pay on the new policy? x Does the new policy provide more insurance coverage?
INSURABILITY: x If your health has changed since you bought your old policy, the new one could cost you more, or you could be turned down. x You may need a medical exam for a new policy. x Claims on most new policies for up to the first two years can be denied based on inaccurate statements. x Suicide limitations may begin anew on the new coverage. IF YOU ARE KEEPING THE OLD POLICY AS WELL AS THE NEW POLICY: x How are premiums for both policies being paid? x How will the premiums on your existing policy be affected? x Will a loan be deducted from death benefits? x What values from the old policy are being used to pay premiums? IF YOU ARE SURRENDERING AN ANNUITY OR INTEREST SENSITIVE LIFE PRODUCT: x Will you pay surrender charges on your old contract? x What are the interest rate guarantees for the new contract? x Have you compared the contract charges or other policy expenses? OTHER ISSUES TO CONSIDER FOR ALL TRANSACTIONS: x What are the tax consequences of buying the new policy? x Is this a tax-free exchange? (See your tax advisor.) x Is there a benefit from favorable “grandfathered” treatment of old policy under the federal tax code? x Will the existing insurer be willing to modify the old policy? x How does the quality and financial stability of the new company compare with your existing company?
*%8 1$,& 53/ )orP-0622V3
2 of 2
Health Insurance Portability and Accountability Act (HIPAA) Authorization to Obtain and Disclose Information
Name of Proposed Insured (Please print.)
Date of Birth
I, the named Insured above or the Personal Representative of the above-named Insured, hereby authorize any health plan, physician, nurse or medical practitioner or practitioner group, health care professional, hospital, clinic, health care facility, laboratory, pharmacy, pharmacy benefit manager, or other health care provider that has provided treatment, services, or payment on my behalf within the past ten (10) years (“My Providers”) to disclose to GBU Financial Life (the ‘Recipient’): •
•
Any and all information relating to the Insured’s health, excluding psychotherapy notes, and the Insured’s insurance policies and claims. This information includes, but is not limited to, information relating to any medical consultations, treatments, or surgeries, hospital confinements for physical and mental conditions, use of drugs or alcohol, drug prescriptions, and communicable diseases including HIV and AIDS, Identifying information about the Insured, including the Insured’s name, address, telephone number, gender, and date of birth.
This authorization to provide the information outlined above also extends to: • • •
any insurance or reinsurance company, including but not limited to any company which may have provided the Insured with life, accident, health, and/or disability coverage, or to which the Insured may have applied for insurance coverage, but coverage was not issued, any consumer reporting agency or insurance support organization, the Medical Information Bureau (MIB, LLC.)
I understand that the information obtained will be used by the Recipient to: • • • •
underwrite my application for coverage, make eligibility risk rating, and policy issuance determinations, obtain reinsurance and administer coverage, determine the Insured’s eligibility for benefits under and/or the contestability of an insurance policy, and detect fraud or abuse and for compliance activities, which may include disclosure to MIB and participation in MIB’s fraud prevention or fraud detection programs and activities.
By signing this authorization, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization and I instruct any physician, health care professional, hospital, clinic, medical facility or other health care provider to release and disclose my entire medical record without restriction, except as specified above.
GBU FINANCIAL LIFE
HIPAA2020 _REV0322
www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428
1
This authorization shall remain valid and in force for thirty (30) months following the date of my signature below. Copy of this authorization is as valid as the original. I understand that I have the right to revoke this authorization in writing, at any time, by sending a written request for revocation to GBU Financial Life, Attention: Chief Underwriter, 4254 Saw Mill Run Boulevard, Pittsburgh, PA 15227-3394. I understand that my revocation is not effective to the extent that any of My Providers, as outlined above, have relied on this Authorization, to the extent that any action has been taken in reliance on this Authorization, or to the extent the GBU Financial Life has a legal right to contest a claim under an insurance policy or the policy itself. I understand that any information that is disclosed pursuant to this authorization may be redisclosed and no longer covered by federal rules governing privacy and confidentiality of health information. I understand that My Providers may not refuse to provide treatment or payment for health care services if I refuse to sign this authorization. I further understand that if I refuse to sign this authorization to release my complete medical record, GBU Financial Life may not be able to process my application, or if coverage has been issued, may not be able to make any benefit payments. I acknowledge that I have received and reviewed a copy of this authorization.
Signature of Proposed Insured
Date
Describe the nature of the Personal Representative’s authority over or relationship to the Proposed Insured
HIPAA2020 _REV0322
2
Human Immunodeficiency Virus (HIV) Test Informed Consent Form Insurer GBU FINANCIAL LIFE Address 4254 Saw Mill Run Blvd. Pittsburgh, PA 15227
In order for us to evaluate your eligibility for insurance coverage, we request that you provide a blood or other bodily fluid sample for testing and analysis. The test performed will determine the presence of antibodies to the Human Immunodeficiency Virus (HIV). By signing and dating this form, you agree that the HIV antibody test may be performed on your blood or other bodily fluid sample and that underwriting decisions may be based on the test results. A positive test will adversely affect your insurance application. It also may result in being uninsurable when you apply for any future life, health or disability. Human Immunodeficiency Virus (HIV) The HIV virus causes a life-threatening disorder of the immune system called Acquired Immune Deficiency Syndrome (AIDS). HIV virus antibodies are found in the blood and other bodily fluids of people who have been exposed to the virus. You do not have to have AIDS to have antibodies against HIV. The virus is spread by sexual contact with an infected person, by exposure to infected blood (as in needle sharing during intravenous drug use or, rarely, as a result of a blood transfusion), or from an infected mother to her newborn infant. The HIV antibody test is actually a series of tests performed on your blood or other bodily fluid sample by an extremely reliable, medically accepted procedure. The testing will be performed by a licensed laboratory. Pre-Testing Condition Many public health organizations recommend a person to seek counseling before taking an HIV antibody test to become informed about the implications of such tests. You may wish to consider counseling, at your expense, prior to being tested. Disclosure of Test Results All tests are confidential, except as authorized by law. State law requires that the laboratory notify the Ohio Department of Health of positive test results. The results of the test will be reported to the insurance company named on your application for insurance. The Insurer may not, by law, release positive test results except as provided below: GBU FINANCIAL LIFE
GBU-NCF-OH-0421
www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428
1 of 3
HIV Test Informed Consent Form (continued) If your HIV antibody test is normal (negative), you will not be notified. You will be notified of an abnormal (positive) test result if you indicate that you desire a positive result be made known to you. You may also identify another person to whom you want the positive results released. If you want a physician or other healthcare provider to be notified of an abnormal HIV antibody test result, you must indicate the name and address of that physician or provider. Abnormal test results may be disclosed to persons hired by the Insurer who participate in medical underwriting decisions of the Insurer. Abnormal test results may also be disclosed to affiliates of the Insurer who require the results for medical underwriting purposes. In addition, if your HIV antibody test is abnormal, a generic code signifying a nonspecific blood, oral fluid (saliva) or urine abnormality may be made known to the Medical Information Bureau (MIB, LLC). The MIB, LLC is an organization of life and health insurance companies that operates as an information exchange on behalf of its members. There will be no record with the MIB, LLC if you had a positive HIV antibody test; however, there will be a record that you have some blood, oral fluid or urine abnormality. If you apply to another MIB-member company for life or health insurance coverage, the MIB, LLC, upon request, will supply the information on you in its file to that member. Test Results While positive test results do not necessarily mean that you have AIDS, it does mean that you are at a greater risk of developing AIDS or AIDS-related conditions if you do not take appropriate medications. If you are infected with HIV, you are infectious to others. You should seek medical follow-up care with your personal health care provider. HIV test results are highly reliable but not 100% accurate. If the test gives you a positive result, you should consider retesting in order to confirm the result. If the test gives a negative result, there is still a small possibility you may be infected with HIV. This is most likely to happen in recently infected persons. It takes at least 4 to 12 weeks for a positive test result to develop after a person is infected and may take as long as 6 to 12 months. Other Sources of Information For more information about AIDS, you may ask a doctor, a nurse, a counselor or call the Ohio AIDS Hotline at 1-800-332-AIDS (2437). The hotline is a free call. Consent for HIV Testing I have read and I understand this HIV Test Informed Consent Form. I voluntarily consent to the withdrawal of blood or to providing another bodily fluid sample, the testing of my blood or other bodily fluid for HIV antibodies and the disclosure of the test results as described above. I will be given a copy of this form. This Consent is valid for ninety (90) days from the date of signature below. The Insurer agrees to complete GBU-NCF-OH-0421
2 of 3
HIV Test Informed Consent Form (continued) testing and provide the authorized notifications, as appropriate, within this ninety- (90) day period. Notification of Positive Test Result In the event of a positive test result: Send the result to me at _________________________________________________________ ________________________________________________________________________________ Address
I authorize GBU Financial Life to send the results to another person: ________________________________________________________________________________ Name ________________________________________________________________________________ Address
I authorize GBU Financial Life to send the results to the following physician or heath care provider: ________________________________________________________________________________ Name ________________________________________________________________________________ Address
Authorization ____________________________________________________________________________________ Name of Applicant
____________________________________________________________________________________ Signature of Applicant Date
____________________________________________________________________________________ Signature of Legal Guardian, If Any Date
____________________________________________________________________________________ Signature of Person Obtaining Consent Date
GBU-NCF-OH-0421
3 of 3
Non-Conforming Illustration/Automatic Transaction Authorization Applicant/Owner’s Acknowledgement
I acknowledge that I did not receive a sales illustration containing full disclosure at the time when I completed the life insurance application. I understand that when the policy is issued, such an illustration will be provided to me at the time the policy is delivered to me. Applicant’s Signature
Date
Automatic Transaction Authorization (previously Check-O-Matic or EFT) The Insurer identified above will be referred to herein as the “Company.” Full Name of Bank
GBU Member
Type: Account Information
GBU Producer—Producer Number:
Checking
Savings
Transaction:
Deposit
Withdrawal
Routing Number (9-digits) Account Number Transaction Date (Choose Day 1-28)
Account Owner
Legal Name (First, Middle Initial, Last) Address (Street, City, State, Zip)
For new business initial automatic transactions, I authorize the Company to make an immediate transaction to/from the bank account listed upon receipt of this form. I authorize the Company to 1) 2) 3) 4)
make electronic deposits, withdrawals and corrections to my bank account that comply with U.S. law; act on this authorization until I revoke it by contacting the Company; apply this authorization to any future bank accounts I may designate; make administrative changes to this authorization which I request such as date and amount changes, or adding or removing contracts for automatic payment; 5) release any and all information related to this authorization to the bank account owner or third-party account owner; and 6) act upon electronic deposit, withdrawal, and administrative instructions I provide to my representative. 7) Notice of debit amounts will not be mailed. Premiums paid to GBU will appear on the bank statement. If this form is received less than ten (10) days prior to the transaction date you entered, your authorization shall take effect on the second occurrence of the mode you have selected. You further acknowledge that if you have selected a deduction to occur on day 29, 30 or 31, the Company will make the transaction on day 28. Bank Account Owner’s Signature Signature (If joint account)
Signature
Date
Legal Name (First, Middle Initial, Last)
Signature
Date
Home Office Use Only Effective Date GBU-NCI.ATA-0721
GBU FINANCIAL LIFE
www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428
1
1035 Exchange Owner’s Name (First, Middle Initial, Last) Personal Information
Email Current Contract/Policy Number Type:
Transferring Firm Information
Social Security Number Annuity Contract
Life Insurance Policy
Firm’s Name
Firm’s Phone
Firm’s Address (Street, City, State, Zip) Note to transferring firm: Make check payable to “GBU Financial Life” and mail to the address below.
I wish to liquidate all funds from the above referenced contract/policy. Expected transfer amount: $ I wish to liquidate a partial withdrawal of funds totaling $ from the above-referenced contract/policy. NOTE: The IRS regulations regarding partial exchanges are not finalized. Not all companies permit partial exchanges. GBU recommends that you consult with your tax advisor regarding the tax consequences of a 1035(a)-partial exchange. I, the undersigned Owner of the above-named contract/policy, hereby assign, and transfer rights, title and interest of the above-named contract/policy to GBU Financial Life (GBU), to be part of a tax-free exchange of existing contracts under Transfer Authorization Internal Revenue Code Section 1035(a). I am aware of, and specifically authorize and approve GBU’s intent to surrender the above-noted contract/policy for the above-stated amount (Check one): Immediately Upon the maturity date of (not to exceed 90 days). Full surrender only (Check one): My contract is attached with this application. I declare that the contract has been lost or destroyed and will not claim any right if found in the future. GBU Policy Number Statement of Understanding Applies When Replacing Life Insurance With An Annuity
I understand that, as a result of the 1035(a) exchange from the above referenced life insurance policy into a GBU annuity, there will be a reduced death benefit (at the time of the exchange) from the amount payable upon the death of the insured under the life insurance contract, to the amount payable upon the death of the owner under the GBU annuity. I understand that the death benefit from the replaced life insurance contract is income tax free to the beneficiary, whereas the gain in the annuity contract will be taxable to the beneficiary as ordinary income. I understand that any tax obligations of this transaction are mine and I am not relying on GBU (nor any of its agents or employees) for any tax advice. Contract Owner’s Legal Name (First, Middle Initial, Last) Contract Owner’s Phone
Contract Owner’s Signature Acknowledgement
Date
Witness’ Legal Name (First, Middle Initial, Last)
Witness’ Signature
Date
Return this completed form to GBU at the below address for an authorized signature and processing. GBU Home Office Authorized Name and Title
GBU Home Office Authorized Signature
Date
GBU FINANCIAL LIFE
EXC09/11-Rev0821
www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428
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Make a Difference: One Member at a Time
GBU believes strongly in the concept of making a difference in the lives of others by recognizing all new members who join the GBU family with a $25 donation to a nationally recognized charity. GBU encourages all new members to participate in this worthwhile program by asking you to select one of the charities listed. By doing this, GBU and you will be joining hands in making a difference for others. www.cancer.org American Cancer Society (Health) Mission Statement: To eliminate cancer as a major health problem by preventing cancer, saving lives, and diminishing suffering from cancer, through research, education, advocacy, and service. www.liverfoundation.org American Liver Foundation (Health) Mission Statement: To facilitate, advocate and promote education, support and research for the prevention, treatment and cure of liver disease. www.redcross.org American Red Cross (Human Services/Disaster Relief) Mission Statement: Prevents and alleviates human suffering in the face of emergencies by mobilizing the power of volunteers and the generosity of donors.
Feeding America (Human Services/Disaster Relief)
www.feedingamerica.org Mission Statement: To feed America’s hungry through a nationwide network of member food banks and engage our country in the fight to end hunger.
Guiding Eyes for the Blind (Human Services)
www.guidingeyes.org Mission Statement: Guiding Eyes for the Blind is dedicated to enriching the lives of blind and visually impaired men and women by providing them with the freedom to travel safely, thereby assuring greater independence, dignity and new horizons of opportunity.
www.toysfortots.org Marine Toys for Tots Foundation (Children/Family Services) Mission Statement: To collect new, unwrapped toys during October, November and December each year and distribute those toys as Christmas gifts to less fortunate children in the community in which the campaign is conducted.
National Center for Learning Disabilities (Education)
www.ncld.org Mission Statement: To improve the lives of the one in five children and adults nationwide with learning and attention issues—by empowering parents and young adults, transforming schools and advocating for equal rights and opportunities. www.npca.org National Parks Conservation Association (Environment) Mission Statement: To protect and enhance America’s National Parks for present and future generations. www.operationtroopappreciation.org Operation Troop Appreciation (Military/Veterans) Mission Statement: To build and sustain the morale and well-being of the military community, past and present, with the assurance that the American public supports and appreciates their selfless service and daily sacrifices. www.humanesociety.org Humane Society of the United States (Animal Rights and Care) Mission Statement: Together with millions of supporters, we take on puppy mills, factory farms, the fur trade, trophy hunting, animal cosmetics testing and other cruel industries. We rescue and care for thousands of animals every year through our Animal Rescue Team’s work and other hands-on animal care services. We fight all forms of animal cruelty to achieve the vision behind our name: A humane society. Please visit GBU at www.gbu.org to learn more about GBU, member benefits and our desire to help others. Member’s Signature _________________________________________________________________________ Email (please print clearly): ____________________________________________________________________
GBU FINANCIAL LIFE
OMT 01.20
www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428
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