Fill - Free fillable Agents will no longer be required to fill (Triadex Services) PDF form

Agents will no longer be required to fill out an application, HIPAA and Disclosure Forms, Bank Draft or Direct

Express Forms and submit these to new business! It’s EZ as 1 - 2 – 3!

1. The Agent makes the final expense sale with client. Using the application worksheet,

Child/Grandchild Supplemental Application, along with the Disclosure Form, the Agent should:

a. Pre-Qualify the client, and Children and/or Grandchildren (if applicable), for the correct plan

using the health questions as a guideline.

b. Gather important client personal, Bank, or Direct Express account information.

c. Have all the required disclosures, including HIPAA, to read and give the client in one easy

detached form. Included is a conditional receipt should you collect the first premium!

2. Once worksheet is completed and disclosures read, the Agent will make the call to DIMA (800-

604-6844) to initiate the Point of Sale Telephone Interview (POSTI) for instant underwriting decision

AND application paperwork completion! Information from the worksheet, and Child//Grandchild Supp

App (if applicable) will be required during this interview from the agent. Complete and accurate data

will make the call smooth and timely.

Please Note: By eliminating the need to fill out and then send in all paperwork, the time will more than

offset the few additional minutes required in the paperless process. The worksheet will allow an agent to

have important client and bank information readily available for the Telephone Interview.

DIMA will begin the process as follows:

a. Ask the Agent client personal and Bank (Direct Express if used to pay premiums) information.

b. Speak with your client to obtain, verify, and underwrite the sale. This includes:

i. Verify disclosures have been read or given to client, including MIB and HIPAA.

ii. Obtain voice signatures for disclosures and application.

iii. Verify health questions (same as worksheet).

iv. Complete Application and all required Forms.

v. Give the Agent an instant underwriting decision before you hang up!

vi. Instruct DIMA where the policy should be sent: To the Agent or Client.

3. The Agent retains the worksheet for their record……..NO need to send in anything and the client’s

policy will be issued. EXCEPT FOR THE FOLLOWING:

a. If the sale is a replacement: The proper state required replacement form(s) must

be completed and signed prior to the call to DIMA.

b. Alabama: Alabama Arbitration Disclosure Form (#CLIC-ARB-AL)

c. California: Medical Eligibility Disclosure (#7404.4-0505) Home Meeting Disclosure

for 65 & Over (7404.2-0505) Financial Product Disclosure 65 & Over (7404.3-0505)

d. Pennsylvania: Disclosure Statement (LBL PA DIS (0806)

Agent must note POSTI reference # on the upper right corner for any required form and fax to new

business @888-525-5002. Failure to do so will delay policy issue and commissions paid.

Final Expense Paperless Application Process Instructions

PO Box 224 Brownwood, Texas 76804-0224 ● 1-888-525-4467 ● FAX 1-888-525-5002 ● E-Mail: newbiz@lbladmin.com

FOR AGENTS USE ONLY!

Check

Appropriate

Company

THE HIGHLIGHTED INFORMATION IS

NECESSARY TO INITIATE UNDERWRITING:

Proposed Insured Full Name:

Date of Birth Present Age

Sex Height Weight

State of Birth Country of Birth

Social Security No. or ITIN

Face Amount $

Have you used tobacco, nicotine, or e-cigarettes in any

form in the past 12 months?

□

YES

□

*****************************************

Street Address

City, State, Zip

Home/Cell Phone

Work Phone

OWNER of Policy (if other than Proposed

Insured)

Relationship

Social Security No.

Address

Home/Cell Phone

Final Expense

Pre-Qualifying Worksheet

SIMPL WORKSHEET 10-2014

Complete this worksheet in order to collect important applicant information BEFORE you call DIMA. Once you

complete this form, please call 800-604-6844 for the application and underwriting completion process. Agent,

Insured, (Owner and/or Payor, if different) must be on the phone at the time of the call. This worksheet contains

sensitive information and should be kept secured for your records or destroyed. DO NOT SEND IN THIS FORM.

Plan Approved For:

□

SIMPL Preferred

□

SIMPL Standard.

□

MWL

Premium Amount $

Amount paid with application $

Premium Mode:

□

Monthly Bank Draft OR

□

Direct Express Card

□

Quarterly

□

Semi-Annual

□

Annual

Primary Beneficiary ____

Relationship

Home/Cell Phone

Contingent Beneficiary

Relationship

Home/Cell Phone

Agent: Agent Number Date:________________

POSTI Reference #: Issue State: Telesales application

□

YES

□

Bank Information: Name of Financial Institution

Routing #:

Account #:

Draft Date:

□ Check here to draft first premium

DIRECT EXPRESS CARD: BENEFIT PAYMENT RESET DATE OF:

 1

of month  3

of month  2

Wednesday 3

Wednesday  4

Wednesday

Direct Express Card Acct. # Exp. Date:

Name as it A

ears on Card:

Final Expense

Pre-Qualifying Worksheet



Use the following health questions to decide which Final Expense plan to offer

If the applicant answers “Yes” to any question in Part 1, DO NOT PROCEED with the application.

Part 1 YES NO

Have you ever been diagnosed have you been diagnosed, treated, tested positive for, or been given medical advice by a

member of the medical profession for:

1. Congestive heart failure (CHF), cardiomyopathy, memory loss, Alzheimer’s, senile dementia,

dementia, heart defibrillator implant, two or more instances of internal cancer(s) or terminal illness? ....................

□ □

2. Organ transplant (other than corneal), untreated Hepatitis C, kidney failure or dialysis, amputation due to

diabetic complications, multiple sclerosis, muscular dystrophy, mental retardation, amyotrophic lateral

sclerosis (ALS) or Lou Gehrig’s disease, Downs’s syndrome, cystic fibrosis or Huntington’s disease? .................

□ □

3. Diabetes at age 9 or younger? .................................................................................................................................... □ □

4. AIDS, AIDS Related Complex, tested positive for HIV virus or any other disorder of the immune system? .......... □ □

Within last 2 years, have you been diagnosed, treated, tested positive for, or been given medical advice by a

member of the medical profession for:

5. Uncontrolled diabetes or uncontrolled high blood pressure? .................................................................................... □ □

Within the last year have you:

6. Been confined to a hospital, been advised to have surgery or hospitalization, used oxygen due to a medical

condition, been unable to care for yourself or been bedridden at home or in a nursing home, hospice, long-term care

or assisted living facility?

Definition of assisted living: requires help in at least one area of skills considered necessary for living and

caring for oneself (feeding, dressing or bathing) .......................................................................................................

□ □

If all “No” answers in Part 1, complete Part 2.

Part 2 Complete all questions and circle the condition(s) to which each “Yes” answer, if any, applies.

YES NO

Within the past 2 years have you been diagnosed , treated, tested positive for, or been given medical advice by a

member of the medical profession for:

(a) Angina (chest pain), any type of heart or circulatory surgery, heart attack, or received a pacemaker or stent? .

□ □

(b) Stroke, Transient Ischemic Attack (TIA/mini-stroke) or paralysis? ...................................................................

□ □

(the term “cancer” includes melanoma, but excludes basal cell skin cancer)? ...................................................

□ □

(d) Aneurysm, brain tumor or sickle cell anemia? ...................................................................................................

□ □

(e) Complications of diabetes such as nephropathy (kidney), neuropathy (nerve, circulatory), retinopathy (eye)

diabetic coma or insulin shock? ......................................................................................................................... □ □

(f) Alcohol or drug abuse, have you used illegal drugs or been convicted of felony or on parole? ........................ □ □

(g) Used a walker, wheelchair or electric scooter due to chronic illness or disease? ...............................................

□ □

If all “No” answers in Part 2, complete Part 3. Otherwise, select MWL & check for state availability.

Part 3 Complete all questions and circle the condition(s) to which each “Yes” answer, if any, applies.

YES NO

Have you ever been diagnosed, treated, tested positive for, or been given medical advice by a member of the

medical profession for:

(a) Chronic Obstructive Pulmonary Disease (COPD), chronic bronchitis, emphysema,

peripheral vascular disease or peripheral artery disease? ................................................................................... □ □

(b) Chronic hepatitis, Hepatitis C, cirrhosis of the liver, chronic pancreatitis, liver disease or kidney

disease? .............................................................................................................................................................

□ □

(c) Insulin use before age 25? ................................................................................................................................. □ □

(d) Irregular heartbeat, atrial fibrillation, Systemic Lupus (SLE), epileptic seizures, Parkinson’s disease? ...........

□ □

If all ‘No” answers in Part 3, select SIMPL Preferred. Otherwise, select SIMPL Standard.

AGENT NOTES:

Replacement Information: (Replacement not allowed for tele-sales) YES NO

1. Does proposed Insured have existing life insurance policies or annuity contracts? .......................................... □ □

2. Will this insurance replace or change any other insurance policies or annuity contracts?................................... □ □

If “Yes” to either question, please provide details of the insurance, including Amount, Company & Plan of Insurance and appropriate

Replacement Form, if required:

Application to Liberty Bankers Life Insurance Supplemental Application for:

P.O. Box 224 Brownwood, TX 76804 Children or Grandchild Rider

LBL-SUPP-APP-0310

1. Supplement to Application on : Check Appropriate Rider

Proposed Insured: Application

Date:

Policy # (When

adding existing rider)

Child

Rider # of

units

Grandchild

Rider $7,500

Address City State Zip Code

2. Children/Grandchild Proposed for Insurance (Please Print)

ame all natural-born children, stepchildren and legally adopted children or grandchildren for grandchild ride

of Primary Proposed Insured

who have not attained age 18. Insurance will not be provided on newborn children less than 15 days of age or grandchildren if grandchild

ride

lied

or.

(

Attach another sheet if necessar

Full Name of Proposed

Insured Child/Grandchild

e Last

Birthday

Sex Date of Birth Relationship to

Proposed

Insured

Hei

ht Wei

3. Health Information

1. Has any Proposed Insured Child/Grandchild ever had, been diagnosed or treated for cancer, diabetes, heart or circulatory

disorder, mental or nervous disorder, mental retardation, cerebral palsy, muscular dystrophy, spina bifida, cystic fibrosis,

un-operated heart defects, epilepsy, asthma, disorders of the muscles or bones, anemia or other disorders of the blood,

bladder, kidneys, liver or lungs?.............................................................................................................. Yes No

2. Has any Proposed Insured Child/Grandchild ever had, been diagnosed or treated by a member of the medical profession

for an Immune Deficiency Disorder, Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)

or tested positive for the Human Immunodeficiency Virus (HIV) ?........................................................ Yes No

3. Has any Proposed Insured Child/Grandchild ever used or received treatment, advice or counseling from a physician or

other practitioner relating to the usage of alcohol, heroin, cocaine, narcotics, hallucinogens, tranquilizers, barbiturates,

amphetamines, or other similar drugs except as prescribed by a physician?............................................. Yes No

Please

rovide details to an

“Yes” answer to Question 1-3

(

Attach another sheet if necessar

Proposed Insured

Child/Grandchild

Condition & Treatment Date Name & Address of Ph

sician

or Hospital

Beneficiar

Desi

nation:

roceeds

able under this rider will be

aid to the Owner, i

livin

. Otherwise,

er the bene

iciar

rovision o

the rider.

1. Does Proposed Insured Child/Grandchild have existing life insurance policies or annuity contracts?.... □ YES □ NO

2. Will this insurance replace or change any other insurance policies or annuity contracts? ………………□ YES □ NO

If “YES” to either question, please provide details of the insurance, including Amount, Company & Plan of Insurance and

appropriate Replacement Form, if required:

I declare and represent that the foregoing statements and answers have been correctly recorded and that they are full,

complete and true to the best of my knowledge and belief and shall constitute a part of the application

Dated at ________________________, __________ on this _________ day of ____________________, ____________.

Signature of Grandparent/Parent Guardian (e-signed)

The electronic signature(s) above fully comply with the Federal Electronic Signature status, Title 15,

U.S.C., Chap. 96, Sec. 7001, et seq., and is therefore fully legal and valid as an original signature.

Agent Statement:

1. Does the Proposed Insured have any existing life insurance policies or annuity contracts?.................... □ YES □ NO

2. Is replacement of existing insurance involved in this application? If yes: Have you submitted

the appropriate replacement forms?........................................................................................................ □ YES □ NO

Signature of Agent: (e-signed) Agent Number

DISCLOSURES for PAPERLESS APPLICATION PROCESS – GENERIC

Included are the three required disclosures (Fair Credit, MIB, and HIPAA) that must be read and given to

your applicant prior to the point of sale telephone interview (POSTI). Your client will be asked to verify

that these were read to them. In addition, the states of Alabama, California, and Pennsylvania require state

specific disclosures that must be completed, signed, and faxed to New Business prior to issuing a policy.

These state required forms may be obtained from the website in the Forms Portal. Agent must note POSTI

reference # on the upper right corner for any required form and fax to new business @888-525-5002.

In addition, included is a conditional receipt should you collect the correct first premium mode.

--------------------------------------------------------------------------------------------------------------------------------------------------

This Notice Must be Given to Proposed Insured

FAIR CREDIT REPORTING ACT PRE-NOTIFICATION FORM. Thank you for considering Liberty Bankers/The Capitol

Life Insurance Company as your insurance carrier. Your application will be processed as quickly as possible. Public Law 91 -5088

requires that we advise you that an investigative consumer report may be made in connection with this application which will

provide applicable information concerning character, general reputation, personal characteristics and mode of living. The

information for this report may be obtained through personal interviews with friends, neighbors, and associates. You are entitled to

be interviewed in connection with an investigative consumer report; and, you have the right to receive a copy of any investigative

consumer report by making a written request within a reasonable period of time.

NOTICE TO APPLICANTS FOR INSURANCE. Information regarding your insurability will be treated as confidential. Liberty

Bankers/The Capitol Life Insurance Company, or its reinsurer(s), may, however, make a brief report of my protected health

information to the MIB, Inc., a not for profit membership organization of life insurance companies, which operates an information

exchange on behalf of its members. If you apply to another MIB, Inc. member company for life and health insurance coverage, or a

claim for benefits is submitted to such a company, the MIB, Inc., upon request from you, will arrange disclosure of any information it

may have in your file. If you question the accuracy of information in the MIB's file, you may contact the MIB, Inc. and seek a

correction in accordance with the procedure set forth in the Federal Fair Credit Reporting Act. The address of the MIB's information

office is 50 Braintree Hill, Suite 400, Braintree, Massachusetts, 02184, telephone 1-866-692-6901, web address: www.mib.com.

Liberty Bankers/The Capitol Life Insurance Company, or its reinsurer(s), may also release information in its file to other life insurance

companies to whom you may also apply for life or health insurance, or to whom a claim for benefits may be submitted.

---------------------------------------------------------------------------------------------------------------------------------------------------

CONDITIONAL RECEIPT – (Cross through if payment is NOT received).

NO INSURANCE WILL BECOME EFFECTIVE PRIOR TO DELIVERY, UNLESS THE FOLLOWING CONDITIONS

HAVE BEEN FULFILLED EXACTLY: INSURANCE ISSUED BASED ON THE APPLICATION WILL TAKE EFFECT

ONLY IF THESE CONDITIONS ARE MET:

That on the effective date the Proposed Insured is insurable as a standard risk under the Company’s rules for the plan amount

and premium rate applied for.

That the sum paid is equal to the FULL FIRST PREMIUM for the policy applied for.

INSURANCE ISSUED BASED ON THE APPLICATION WILL TAKE EFFECT ON THE LATEST OF:

(a) date of the application; or (b) date requested in the application; or

The total amount of insurance which may become effective prior to delivery of the policy to the Owner shall not exceed $25,000.

This amount includes LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS then IN FORCE or APPLIED FOR with this

Company. LIBERTY BANKERS/THE CAPTIOL LIFE INSURANCE COMPANY has received $

for Applicant

Agent’s Signature Date

THE PREMIUM CHECK MUST BE MADE PAYABLE TO LIBERTY BANKERS/THE CAPITOL LIFE INSURANCE COMPANY. DO

NOT MAKE THE CHECK PAYABLE TO THE AGENT OR LEAVE THE PAYEE BLANK.

Administrative Office: P O Box 224

Brownwood, Texas 76804

1-800-604-8002

AUTHORIZATION TO OBTAIN, RELEASE AND DISCLOSE MEDICAL INFORMATION

I hereby authorize any: medical practitioner, physician, hospital, clinic, pharmacy benefit manager, or other medical related

facility, insurance company, insurance support organization, business partner, pharmacy, government agency, group policy

holder, employer, benefit plan administrator, the MIB, Inc., the Department of Motor Vehicle Registration, and paramedical

facility to provide to LIBERTY BANKERS LIFE INSURANCE COMPANY/THE CAPITOL LIFE INSURANCE

COMPANY, or to any agent, attorney, consumer reporting agency or independent administrator, including medical record

retrieval services or pharmaceutical services, acting on LIBERTY BANKERS LIFE INSURANCE COMPANY/THE

CAPITOL LIFE INSURANCE COMPANY, or its reinsurers’ behalf, information concerning advice, care, or treatment sought

by or provided to me and/or any other applicant for coverage, including information relating to medical history, medical

conditions, treatment, hospitalizations or confinements, ailments, pharmacy prescription drugs, and/or drug, alcohol or tobacco

usage of the applicant(s). It is understood that LIBERTY BANKERS LIFE INSURANCE COMPANY/THE CAPITOL LIFE

INSURANCE COMPANY’s underwriters, claim examiners, reinsurers, attorneys, or the medical director may disclose such

health information to the aforementioned parties for purposes of underwriting, compliance, record clarification or explanation,

or 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 authorize LIBERTY BANKERS LIFE INSURANCE

COMPANY/THE CAPITOL LIFE INSURANCE COMPANY, or its reinsurers, to make a brief report of my protected health

information to the MIB, Inc.

I understand that:

• such information will be used by LIBERTY BANKERS LIFE INSURANCE COMPANY/THE CAPITOL LIFE

INSURANCE COMPANY for underwriting and insurability determinations;

• I may refuse to sign this authorization and that my refusal to sign will affect my ability to obtain life insurance coverage;

• a picture copy or photocopy of this authorization shall be as valid as the original; and

• any authorized representative of the proposed insured is entitled to receive a copy of this authorization upon request.

This authorization is valid from the date signed for a duration of 24 months. I understand I may revoke the authorization at any

time, except to the extent that action has been taken in reliance on this authorization, by sending written notice to the Life

Underwriting Department of LIBERTY BANKERS LIFE INSURANCE COMPANY/THE CAPITOL LIFE INSURANCE

COMPANY, P. O. Box 224, Brownwood, Texas 76804. I may inspect or copy any information used or disclosed under this

authorization, if signed.

Date

Proposed Insured (Please print) Signature of Proposed Insured (or parent if Proposed Insured is

under age 16)

Birthdate

Additional Proposed Insured (Please print) Signature of Additional Person Proposed for Insurance

Birthdate

Personal Representative designated by signature above is hereby

authorized to execute this instrument based on:

power of attorney, guardian-in-fact, guardian, payee,

representative, other (Circle one)

LBL-HIPAA-2012-08-23

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

Agents will no longer be required to fill (Triadex Services)

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank Agents will no longer be required to fill (Triadex Services) Form

Related forms

Fillable Agents will no longer be required to fill (Triadex Services)

Fill Online, Printable, Fillable, Blank Agents will no longer be required to fill (Triadex Services) Form

Related forms

First 20 documents completely FREE!