this is only a sample application. it is not a promise to issue … · 2019. 10. 6. · this is...

This is only a sample application. It is not a promise to issue coverage.

You cannot buy this application directly from Royal Neighbors of America.

It is sold only via licensed agencies such as Choice Mutual.

To apply, call Choice Mutual (licensed to sell from Royal Neighbors of America products)

at 1-800-644-2926.

1. EXISTING or APPLIED FOR INSURANCE Does the Proposed Insured have any existing or applied for life insurance (L) or annuity (A) contracts with this or any other company? � Yes � No If Yes, complete and submit state replacement forms, if required, with this application and provide details

of all insurance, existing or applied for:

2. REPLACEMENT In connection with this application, has there been, or will there be, with this or any other company any: surrender transaction;

loan; withdrawal; lapse; reduction or redirection of premium/consideration; or change transaction (except conversions) involving an annuity or other life insurance? � Yes � No If Yes, complete and submit a replacement questionnaire AND any other staterequired replacement forms with this application.

ICC161743 Rev. 8-2016 ICC161743 Page 1 of 9

Application for Individual Life InsuranceA Fraternal Benefit Society

PART 1

SECTION 2 – Other Insurance

Multiple Beneficiaries will receive an equal percentage of proceeds unless otherwise instructed.❎ PRIMARY � PRIMARY � CONTINGENTName________________________________________________ Name ________________________________________________Street ________________________________________________ Street ________________________________________________City _________________________ State ______ ZIP_______ City _________________________ State ______ ZIP _______DOB ____________ SSN/Tax ID_________________________ DOB____________ SSN/Tax ID __________________________Relationship to Proposed Insured __________________________ Relationship to Proposed Insured____________________________Percent of proceeds________________% Percent of proceeds________________%

SECTION 4 – Beneficiary(ies) (If you have additional beneficiaries, please see page 4)

**Complete if Proposed Owner is other than Proposed Insured or Proposed Insured is under age 151/2

Sex � M � F SSN/Tax ID ________________________ Relationship to Proposed Insured __________________________

Name________________________________________________ � U.S. driver’s license � Government issued ID ST ________Street ________________________________________________ ID number __________________________________________City_________________________ State______ ZIP ______ Phone number ( )_________________ DOB ____________

Are you a U.S. citizen? � Yes � No Email address __________________________________________

If No, are you a legal U.S. resident (Green Card)? � Yes � No

SECTION 3 – Proposed Owner/Petitioner**

Royal Neighbors of America230 16th StreetRock Island, IL 61201Toll-free (800) 627-4762

Name ______________________________________________ Street_______________________________________________City ______________________________________________ State______ ZIP_____________ Years at this address*________ SSN/Tax ID ________________________________________ *If less than 3 yrs., add prior residence address in additional info, pg .4.DOB_______________State/Country of birth________________ Marital status � S � M � D Sex � M � F Phone number ( ) ________________________________� U.S. driver’s license � Government issued ID ST ________ Annual income $______________Net worth $ ________________ID number ________________________________________ Employer’s name ______________________________________Email ________________________________________________ Position/Title __________________________________________Education � High school � 1+ college � Bachelors � Advanced Duties______________________ Length of employment________Are you a U.S. citizen? � Yes � No If No, are you a legal U.S. resident (Green Card)? � Yes � No Do you wish to designate another person (secondary addressee) to receive copies of any premium lapse notices? Yes NoName________________________ Address______________________________________ Phone (______)___________________

SECTION 1– Proposed Insured

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Company (L, A) Insurance Issue Death Amount Applied for

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SECTION 6 – General Risk Questions Has the Proposed Insured:

1. In the past 5 years, have you used chewing tobacco, cigarettes, cigars, or other tobacco products, or used any nicotine delivery products such as e-cigarettes, nicotine gum, lozenges or patch? � Yes � No If Yes, identify the date last used:2. In the past 5 years, done any flying other than as an airline passenger, or engaged in vehicle racing, underwater diving, or sky diving? � Yes � No 3. Any current service with or entered into a written agreement to become a member of the armed forces? � Yes � No4. In the past 5 years, been convicted of one or more vehicle moving violations, driving under the influence of alcohol or drugs, or ever had a driver’s license revoked or suspended? � Yes � No5. Ever had an application for life or health insurance declined, postponed, up-rated, or modified, or any insurance cancelled or its renewal refused? � Yes � No6. In the past 5 years, have you claimed disability benefits for an injury, illness, or impaired condition? � Yes � No7. Ever pleaded guilty to or been convicted of a felony or misdemeanor? � Yes � No8. Any plans within the next 2 years to travel or reside outside the U.S.? � Yes � NoHas the Proposed Insured or Proposed Owner:9. Entered into any agreement or arrangement providing for the future sale of the insurance Certificate applied for in this application? � Yes � No10. Entered into any agreement or arrangement where the Proposed Insured will receive financing or a loan, including forgivable loans, to pay some or all of the premiums, costs, or other expenses associated with this loan? � Yes � No11. Entered into any agreement either orally or in writing by which you are to receive any form of consideration in exchange for procuring the insurance Certificate you are applying for? � Yes � No

Details: If you answered YES to General Risk questions 2–11, please provide details below.


1. FACE AMOUNT $_________________________

2. RISK CLASS QUOTED _____________________

3. PRODUCT

SECTION 5 – Information Regarding Insurance Applied For

5. DIVIDEND OPTION � Applied to the payment of current premiums � Paid in cash � Applied to purchase paid-up additional insurance (Not applicable to Universal Life) � Left on deposit to accumulate at interest

6. RIDERS (Check state availability) � Accelerated Living Benefit Rider (Ter� only) � Accelerated Death Benefit - Terminal Illness (UL and WL only.) � Accelerated Death Benefit - Chronic Illness (UL and WL only Choosing this rider may affect eligibility for Government Programs.)

� Accelerated Death Benefit - Critical Illness (UL and WL only. Choosing this rider may affect eligibility for HDP.)

� Accidental Death Face Amount: $__________________ � Guaranteed Insurability Rider � Premium Waiver Disability � Waiver of Monthly Deduction � Cancer Waiver � Child Rider � Flexible Premium Deferred Annuity Rider Planned Premium $_____________ (Mode is same as base certificate.)

B. UNIVERSAL LIFE

� Cash Accumulation Death Benefit Type: � Option A or � Option B Planned Premium $___________

� Death Benefit Guarantee Death Benefit Type: � Option A only Planned Premium $___________

4. AUTOMATIC PREMIUM LOAN (APL)will be provided.

� No Check if APL is NOT desired. (Not applicable to Universal Life)

❎ Accelerated Death Benefit -Terminal Illness (to remove, strikethrough and Proposed Ownerinitial here _____________.)

� Accelerated Death Benefit -Chronic Illness (choosing thisrider may affect eligibility forGovernment Programs.)

� Accelerated Death Benefit -Critical Illness (choosing this ridermay affect eligibility for HDP.)

� Accidental Death Face Amount: $____________

� Guaranteed Insurability Rider

� Premium Waiver Disability

� Waiver of Monthly Deduction

� Cancer Waiver

� Child Rider

� Flexible Premium Deferred Annuity Rider Planned Premium $__________(Mode is same as base Certificate.)

A. WHOLE LIFE� Level Pay (to age 121)

� Paid-up at Age 65

� 20-Pay Life

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PART 2 (If exam is required, then PART 2 is optional. Please skip to PART 3.)

Please provide name of doctor, practitioner, or health care facility who can provide the most complete and up-to-date informationconcerning the present health of the Proposed Insured.

Physician name ____________________________________ Name of practice/clinic____________________________________

Street ____________________________________________ City, State, ZIP ________________________________________

Phone number ( ) ______________________________ Fax number ( ) ______________________________________

Date last consulted_______________ Provide reasons for visit and the results.________________________________________________

____________________________________________________________________________________________________________

List all currently prescribed medications, dosage, and frequency. ______________________________________________________

____________________________________________________________________________________________________________

SECTION 1 – Proposed Insured Physician Information / Medical Information

� P � S� P � S

Details: If you answered YES to questions 3–7 in Section 1, please provide details here.

Question # Name of Physician/Address Illness Date/Duration Diagnosis/Medications/Treatments

1. Height_______ Weight_______ Experienced a change in weight (greater than 10 pounds) in the last 12 months? � Yes � No If Yes, specify: Pounds lost_______ Pounds gained ____________________________________________________________2. Are your parents (P) or any siblings (S) deceased, or have they ever been treated by a member of the medical

profession for heart disease, diabetes, cancer, or mental illness? (If Yes, indicate below) .............................................. � Yes � No Relationship Age at death Diagnosis, cause of death

3. Have you ever received counseling or treatment from any physician for, or been advised by a physician to discontinue the use of alcohol or the use of prescribed, or non-prescribed drugs? .................................................... � Yes � No

4. In the past 10 years have you used amphetamines, barbiturates, cocaine, narcotics, marijuana, or other depressant,excitant, or hallucinatory drugs, unless administered on the advice of a physician?................................................... � Yes � No

5. Have you ever been diagnosed by a member of the medical profession or tested positive for Human ImmunodeficiencyVirus (AIDS virus) or Acquired Immune Deficiency Syndrome (AIDS)? ............................................................................ � Yes � No

6. Have you ever been diagnosed as having, been treated by a member of the medical profession for, or tested positive for: a. Heart attack; high blood pressure; stroke; TIA, cerebrovascular disease, or other disorder of the heart or blood vessels ? ............ � Yes � No b. Cancer, tumor, cyst, mass; leukemia; lymph gland; thyroid; anemia or any other blood abnormalities? ................ � Yes � No

c. Diabetes or other endocrine disorder; sugar, albumin, or blood in urine; pancreatitis; disorder of kidney, bladder, or prostate? .. � Yes � No d. Asthma; bronchitis; emphysema; pneumonia; tuberculosis; or any other disorder of the lung/respiratory system? ..... � Yes � Noe. Intestinal bleeding; ulcer; hepatitis; or other disorder of throat, stomach, liver, intestine, or gallbladder?............ � Yes � Nof. Any disease or disorder of the reproductive system or breasts? ............................................................................ � Yes � Nog. Brain, mental, or emotional nervous disorder; dementia, Alzheimer’s, eye disorder; epilepsy, seizures,

paralysis; depression; anxiety; or any other disease or disorder of the nervous system?......................................... � Yes � Noh. Arthritis; loss of limb, or deformity; disorder of bone, joint, muscle, back, or spine; skin disorder, lupus,

connective tissue disorder; or any other disorder of the musculoskeletal system? ............................................... � Yes � No7. Excluding tests related to Human Immunodeficiency Virus (AIDS virus), during the past 5 years, have you: a. Had any surgery or diagnostic test, such as an electrocardiogram, X-ray, MRI, CT scan, biopsy, or blood study? � Yes � No b. Been advised to have any diagnostic test, hospitalization, or surgery that has not been completed? ..................... � Yes � No

c. Had treatment as an inpatient or outpatient or are you currently confined in a hospital, institution, clinic, or other medical facility? ....................................................................................................................................... � Yes � No


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Multiple Beneficiaries will receive an equal percentage of proceeds unless otherwise instructed.

� PRIMARY � CONTINGENT � PRIMARY � CONTINGENTName________________________________________________ Name ________________________________________________Street ________________________________________________ Street ________________________________________________City _________________________ State ______ ZIP_______ City _________________________ State ______ ZIP _______DOB ____________ SSN/Tax ID_________________________ DOB____________ SSN/Tax ID __________________________Relationship to Proposed Insured __________________________ Relationship to Proposed Insured____________________________Percent of proceeds________________% Percent of proceeds________________%

� PRIMARY � CONTINGENT � PRIMARY � CONTINGENTName________________________________________________ Name ________________________________________________Street ________________________________________________ Street ________________________________________________City _________________________ State ______ ZIP_______ City _________________________ State ______ ZIP _______DOB ____________ SSN/Tax ID_________________________ DOB____________ SSN/Tax ID __________________________Relationship to Proposed Insured __________________________ Relationship to Proposed Insured____________________________Percent of proceeds________________% Percent of proceeds________________%

Additional Information


Additional Beneficiaries

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We, the Proposed Insured, Proposed Owner, or Proposed Petitioner, if applicable, have read this application for life insurance including anyamendments and supplements and, to the best of our knowledge and belief, all statements are true and complete. We also agree that:

• Statements in this application and any amendment(s), paramedical/medical exam, and supplement(s) are the basis of any certificate issued.

• This application and any amendment(s) paramedical/medical exam, and supplement(s) to this application will be attached to and, alongwith the articles of incorporation and bylaws of Royal Neighbors of America (Royal Neighbors), become part of the new Certificate, andany copy or electronic image of these documents are as valid as the original and may be relied upon by Royal Neighbors in determiningwhether to issue the insurance for which I applied.

• No information will be deemed to have been given to Royal Neighbors unless it is stated in this application and amendment(s),paramedical/medical exam, and any supplement(s).

• Only authorized officers of Royal Neighbors may: a) make or change any contract of insurance; b) make a binding promise aboutinsurance; or c) change or waive any term of an application, receipt, or Certificate.

• Corrections, additions, or changes to this application may be made by Royal Neighbors. Any such changes will be shown under“Corrections and Amendments.” Acceptance of a Certificate issued with such changes will constitute acceptance of the changes. No changewill be made in classification (including age at issue), plan, amount, or benefits unless agreed to in writing by the Applicant.

• Unless otherwise provided by a Conditional Receipt, Royal Neighbors will have no liability under this application unless and until: a) ithas been received and approved by Royal Neighbors at its Home Office; b) the Certificate has been issued and delivered to theCertificateowner; c) the first premium has been paid to and accepted by Royal Neighbors or authorization to draft first payment has beengiven and the financial institution has not notified Royal Neighbors that the draft will not be honored; and d) at the time of delivery andpayment, the facts concerning the insurability of the Proposed Insured are as stated in this application.

• If not a current member, the Proposed Insured, applies to become a member of Royal Neighbors as indicated by the signature on page6 and as a member, agrees to uphold the principles of Faith, Unselfishness, Courage, Endurance, and Humility upon which RoyalNeighbors of America was founded more than 120 years ago.

Taxpayer Identification Number CertificationUnder penalties of perjury, We, the Proposed Insured, or Parent, if a minor, or Proposed Owner certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and

2a. – I am not subject to backup withholding because: a) I am exempt from backup withholding, or b) I have not been notifiedby ue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or c) theIRS hat I am no longer subject to backup withholding, and

b – I am not subject to backup withholding because: a) I am exempt from backup withholding, or b) I have not been notifiedby ue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or c) theIRS has notified me that I am no longer subject to backup withholding, and

3. I am a U.S. citizen or other U.S. person.

Certification instructions: You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backupwithholding because you have failed to report all interest and dividends on your tax return. The IRS does not require your consent to any part ofthis form other than the certifications required to avoid backup withholding.

Agreement/Acknowledgement/Disclosure

*If face amount is over $1 million or within the past 12 months the Proposed Insured has been treated by a member of the medical profes-sion for heart trouble, stroke, or cancer, then payment (including drafting first payment) cannot be accepted with the application. Do notsubmit EFT form.

1. PAYMENT MODE (Check one) 2. BILLING ADDRESS INFORMATION

Direct bill: � Annual � Semi-Annual � Quarterly � Proposed Insured’s address � Proposed Owner/Petitioner’s addressElectronic check/EFT: (Complete form on page 7) � Other Premium Payor’s/Alternate billing address (details below)� Annual � Semi-Annual � Quarterly � Monthly Name ______________________________________________� *Payment with app $______________ � *Draft first payment Street ______________________________________________Additional details ____________________________________ City_________________________ State______ ZIP ________

SECTION 1 – Payment Information PART 3


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Authorization I, the Proposed Insured, or Parent, if a minor, hereby authorize any licensed physician, medical practitioner, hospital, clinic, laboratory,pharmacy, pharmacy benefit manager, or other medical facility, insurance or reinsurance company, MIB, Inc., consumer reportingagency, division of motor vehicles, the veterans administration, or other government agency or department having information as to thediagnosis, treatment, or prognosis with respect to any physical or mental condition, or having any non-medical information includingany individually identifiable information, concerning me to release and disclose the entire medical record and any other protected healthor other information concerning me within the past 10 years, without restriction, to Royal Neighbors, its agents, employees,representatives, or its reinsurers. I further authorize Royal Neighbors, or its reinsurers, to make a brief report of my personal healthinformation to MIB. This includes information on the treatment for alcohol, drug, and tobacco abuse, and psychiatric diagnosis andtreatment. In order to facilitate the rapid transmission of such information, I authorize all the sources named above, except MIB,to give such information to any legal representative or agent employed by Royal Neighbors. I understand this authorizationcomplies with the HIPAA Privacy Rule.I understand that the protected information is to be disclosed under this authorization so that Royal Neighbors may underwrite myapplication for life insurance, determine my eligibility for insurance, risk rating, or certificate issuance determinations, obtainreinsurance, administer claims and determine or fulfill responsibility for coverage and provision of benefits, administer coverage, andconduct other legally permissible activities that relate to any coverage I have applied for with Royal Neighbors. Any protectedinformation obtained will not be released and/or reported by Royal Neighbors or its reinsurers to any person or organization EXCEPTto other divisions and/or departments of Royal Neighbors or its reinsuring companies, MIB, other life/health insurance organizations orfraternal benefit societies with which I have insurance contracts or to whom I may apply for insurance or to whom a claim for benefitsmay be submitted, or other persons or organizations performing business or legal services in connection with my application, theinsurance Certificate, or claim for benefits or as may be otherwise lawfully required or as I may further authorize.I understand that this authorization shall remain in force for 24 months or as permitted by applicable law in the state where theCertificate is delivered or issued for delivery from the date signed if used in connection with an application for life insurance certificate,an application for reinstatement of a life insurance certificate, or a request for change in Certificate benefits; or for the duration of a claimif used for the purpose of collecting information in connection with a claim for benefits under a certificate.I understand and agree that a copy of this authorization is as valid as the original and that I or my authorized representative is entitled toreceive a copy. I understand that this authorization may be revoked by me at any time in writing, and if I refuse to sign or if I subsequentlyrevoke this authorization, Royal Neighbors may not be able to process this application, and if coverage has been issued, may not be ableto process any benefit payments. I agree that Royal Neighbors shall be fully protected if it acts in reliance on this authorization prior toreceiving notice of revocation at its Home Office or to the extent that Royal Neighbors has a legal right to contest a claim under aninsurance contract. Any information that is disclosed pursuant to this authorization may be re-disclosed to such entities or as required orauthorized by law and may then no longer be covered by federal rules governing privacy and confidentiality of health information.

Corrections and Amendments (For Home Office Use Only)

FRAUD NOTICE/WARNING: Any person who knowingly presents a false statement in an application for insurance maybe guilty of a criminal offense and subject to penalties under state law.

� er Disclosure Statement, Form 9745-A, from my agent, if applicable.

SIG S g ed at c ty, state __________________________________________ Date__________________

Proposed Insured ________________________________________________________________(Sign if age 12 or older)

Signed at city, state __________________________________________ Date__________________

Proposed Owner/Petitioner ________________________________________________________

Signed at city, state __________________________________________ Date__________________

Signature of Parent________________________________________________________________(Required for all applicants under age 18)

�

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Proposed Insured1. Do you have any knowledge or reason to believe the Proposed Insured has any existing or applied for life insurance

or annuity contracts with this or any other company? ............................................................................................... � Yes � No2. Do you have any knowledge or reason to believe the Proposed Insured has in-force life insurance or annuity

contracts that may be replaced as a result of this transaction? ................................................................................... � Yes � No3. If Yes, and applicable, have you completed a replacement questionnaire and any other state required replacement forms? .................................................................................................................................................. � Yes � No4. Did you personally review the I.D. of the Proposed Owner? � Yes � No If Yes, form of I.D. __________________________5. Did you personally review the I.D. of the Proposed Insured? � Yes � No If Yes, form of I.D. __________________________6. What is the premium to annual income ratio (annual premium divided into annual income)? _____________________________ 7. Was the Conditional Receipt left? ............................................................................................................................. � Yes � No8. Did you use written sales material approved for use by Royal Neighbors? ................................................................... � Yes � No9. Was Rider Disclosure Statement, Form 9745-A, delivered and signed by you and the Proposed Insured and Proposed

Owner, if applicable? .................................................................................................................................................. � Yes � No

Note: Refer to language at top of Conditional Receipt for circumstances when Conditional Receipt should not be used.

Agent no.____________________________ Agent license no. ____________________________________

Signature of Writing Agent __________________________________________ Date ________________

Printed name of Writing Agent ______________________________________________________________

If applicable, complete the following:Agent Name ______________________________________________ ID Number ________________ Percent ____________

Please print

�

Signature as it appearson bank records X __________________________________________________ Date ________________

Authorization for Electronic Funds Transfer (EFT)

�

A Fraternal Benefit Society

Royal Neighbors of America230 16th St.,Rock Island, IL 61201(800) 627-4762

Agent’s Report


I authorize Royal Neighbors of America and the bank named below to initiate automatic withdrawals from my checking/savingsaccount. This authority will remain in effect until I give Royal Neighbors or the bank reasonable notice to stop payment on anywithdrawal. (Royal Neighbors requires three days notice prior to scheduled withdrawals.)

� Check to use bank information from attached voided check. Form must still be signed, dated, and payment selected.

Name of financial institution __________________________________________________________________________City ________________________________________________________ State ______________________________Name (please print)____________________________________________ Phone number ( ) __________________Address/PO Box __________________________________________________________________________________City ______________________________________________________________ State_____________ ZIP __________

I would like the payment withdrawn on the ___ ___ day of the month (Quarterly, semi-annual, or annual payments also available.)OR the _____2nd _____3rd _____4th Wednesday of the month. (If nothing is selected withdrawals will default to the5th day of the month.) Routing # ____________________ Checking acct # ____________________ OR Savings acct # ___________________

(DEBIT AND CREDIT CARD NUMBERS ARE NOT ACCEPTABLE)

PLEASE RETURN THIS AUTHORIZATION WITH A VOIDED CHECK.

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Conditional Receipt

Unless each and every condition specified below is fulfilled exactly, no insurance will become effective prior to delivery of the Certificateof insurance. No agent of Royal Neighbors of America (Royal Neighbors) is authorized to alter or waive any of the conditions. Received from _____________________________ (Date)___________ the sum of $______________ � Check � By drafting first premium

Proposed Insured: ____________________________________ Life Insurance Amount: $_______________ Plan: ________________1. All of the following conditions must be met before insurance on the Proposed Insured may become effective prior to delivery of the Certificate:

a) The payment indicated above must have been received by Royal Neighbors or anticipation to draft first payment has been given andthe financial institution has not notified Royal Neighbors that the draft will not be honored and be at least equal to an amountsufficient to keep the Certificate in force for at least one month at the premium class applied for. Provided, however; assuming all otherconditions under this paragraph 1 have been met, if Royal Neighbors, in accordance with its rules, would have issued the Certificateunder a different premium class than applied for, and the premium paid was less than the premium that would have been required forthe issuance of a certificate at this new premium class, then the death benefit payable under the receipt shall be such as the premium paidwould have purchased at this new premium class.

b) All medical examinations and tests required by Royal Neighbors must be completed and received at the Home Office of Royal Neighbors.c) As of the Effective Date, as defined below, the Proposed Insured must be a standard risk under rules and practices of Royal

Neighbors for the plan and the amount of life insurance applied for, without change and at the rate of premium paid.d) As of the Effective Date, the state of health and all factors affecting the insurance of the Proposed Insured must be as stated in the application.

2. When each and every one of the conditions of paragraph 1 have been met, then the lesser of, (a) the insurance coverage, as provided bythe terms and conditions of the certificate of life insurance applied for, including accidental death coverage if applicable; or (b) insurancecoverage in the amount of $1,000,000; will begin as of the Effective Date. “Effective Date” as used herein, means the later of:a) the date of completion of the application; orb) the date of completion of all medical examinations, electrocardiograms, blood/urine tests, and other tests required by Royal Neighbors.

3. There will be no conditional insurance coverage and Royal Neighbors’ liability will be limited to returning any premium submitted toRoyal Neighbors with this Conditional Receipt if any of the following occurs: (a) one or more of the Conditional Receipt’s conditions havenot been met exactly; (b) the Proposed Insured dies by suicide; or (c) Royal Neighbors does not approve and accept the application forinsurance within sixty (60) days from the date of the Conditional Receipt.

NO AGENT OR OTHER PERSON IS AUTHORIZED BY ROYAL NEIGHBORS TO WAIVE OR MODIFY ANY OF THEPROVISIONS OF THE CONDITIONAL RECEIPT.

Signature of Agent Receiving the Payment__________________________________________________________

I understand and agree to the terms, conditions, and limits of this receipt and the agreements in the application, all of

which have been fully explained to me by the agent.

Signature of Proposed Owner/Petitioner __________________________________________________________

�

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A Fraternal Benefit Society

Royal Neighbors of America230 16th StreetRock Island, IL 61201Toll-free (800) 627-4762

*** MUST BE LEFT WITH PROPOSED INSURED/OWNER ***

IMPORTANT: If face amount is over $1 million or if within the past 12 months the Proposed Insured has been treated by amember of the medical profession for heart trouble, stroke, or cancer, payment (including authorization to draft the firstpremium) cannot be received with application and no conditional receipt may be given and there will be no coverage under anyconditional receipt.


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This Notice is to be detached, read, and retained by the Proposed InsuredInformation regarding your insurability will be treated as confidential. Royal Neighbors or its reinsurers make a brief report thereon tothe MIB, Inc., a not-for-profit membership organization of insurance companies which operates an information exchange on behalf ofits members. If you apply to another MIB member company for life or health insurance coverage, or if a claim for benefits is submittedto such a company, MIB, upon request, will supply such company with the information in its file.

Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your file. Please contact MIBat (866) 692-6901. If you question the accuracy of information in MIB’s file, you may contact MIB and seek a correction in accordancewith the procedures set forth in the Federal Fair Credit Report Act. The address of MIB’s information office is: MIB, 50 Braintree HillPark, Suite 400, Braintree, MA 02184.

Royal Neighbors or its reinsurers may also release information in its file to other insurance companies to whom you apply for life orhealth insurance, or to whom a claim for benefits may be submitted.

This is to inform you that as part of our underwriting procedures in connection with this application, an investigative consumer reportmay be obtained on the Proposed Insured and the Proposed Petitioner. This report will provide applicable information concerningcharacter, general reputation, personal characteristics, and mode of living.* This information will be obtained through personalinterviews with neighbors, friends, and associates. You may request to be interviewed in connection with the preparation of theinvestigative consumer report. You have the right to make a written request within a reasonable period of time to receive additionaldetailed information about the nature and scope of this investigation. No information collected concerning the sexual orientation of theProposed Insured or Proposed Petitioner will be used to determine her or his eligibility for life insurance.

*Information obtained will not be used to determine sexual orientation.

Fair Credit Report Act Notice

MIB, Inc., Notice

*** MUST BE LEFT WITH PROPOSED INSURED ***

Royal Neighbors of Americawww.royalneighbors.org

Rock Island Home Office • 230 16th St., Rock Island, IL 61201 • (800) 627-4762


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this is only a sample application. it is not a promise to issue … · 2019. 10. 6. · this is...

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