Fillable Application for Guaranteed Issue Whole Life Insurance Graded

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Application for Guaranteed Issue Whole Life Insurance Graded

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The Application for Guaranteed Issue Whole Life Insurance Graded form is 2 pages long and contains:

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  • 16 check-boxes
  • 41 other fields

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AGLC108847-FL-2015 Page 1 of 2
Rev0916
Application for Guaranteed
Issue Whole Life Insurance
Graded Death Benefit
Florida Version
American General Life Insurance Company,
2727-A Allen Parkway, Houston, TX, 77019
A member of American International Group, Inc. (AIG)
PART 1: TELL US ABOUT YOURSELF
First Name Middle Initial Last Name
Home Street Address
City State Zip
Date of Birth Place of Birth (State/Country)
Primary Phone Alternate Phone
Gender: l Male l Female Social Security Number
E-mail Address
Are you a United States citizen or do you have Permanent Legal Resident (Green Card) status? l Yes l No
PART 2: TELL US ABOUT THE COVERAGE YOU ARE REQUESTING
What amount of insurance are you applying for?
Amount of Life Insurance: $ (from $5,000-$25,000)
Do you plan to replace, cancel, or change any other existing life insurance or annuity with this policy?
l Yes l No
Beneficiary Designation: Who do you want the insurance proceeds to go to? (If more than one beneficiary is designated, proceeds
will be divided equally unless you indicate a share.)
Beneficiary #1
Beneficiary Name (please print) Relationship to You %Share
Beneficiary #2
Beneficiary Name (please print) Relationship to You %Share
PART 3: HOW WILL YOU PAY FOR COVERAGE?
How often do you want to pay?
l
Annually l Semi-annually l Quarterly l Monthly
Your premium amount for the payment frequency selected above is: $
How will you pay?
[Check one]
l Bank Draft (Complete Bank Draft Authorization)
l Credit Card (Complete Credit Card Authorization)
l Bill me Directly (Monthly premium frequency not available with this payment method)
l Other (please explain)
N/A
AGLC108847-FL-2015 Page 2 of 2
Rev0916
Who will pay for your coverage?
(Complete only if the person paying for this policy is someone other than you)
First Name Middle Initial Last Name
Home Street Address Gender: l Male l Female
City State Zip
Date of Birth Relationship to You
Is the Premium Payor a United States citizen or does the Premium Payor have Permanent Legal Resident (Green Card) status?
l Yes l No
(If “Bank Draft” or “Credit Card” is not the chosen form of payment, then also complete the Payor authorization form)
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
I agree that:
• To the best of my knowledge and belief, all statements in this application for life insurance are true and complete.
• My statements in this application and any amendment(s) are the basis of any policy issued.
• I understand that no insurance will take effect until a policy is delivered to me and the full first premium due is paid.
• I have not previously applied for this product in the last 12 months.
• I understand that the total combined amount of all American General Life Insurance Company guaranteed issue whole life
insurance benefits on my life cannot exceed $25,000.
Signature of Proposed Insured Date
Agent Name (please print)
State License #
Agent Signature
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Application for Guaranteed Issue Whole Life Insurance Graded

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Completed 22 March 2022

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