+1 (866) INSUBUY
Insurance can be effective only after the underwriting department receives and reviews your
application. The earliest effective date will be the next day after the review.
Underwriting department is open from Monday through Friday, 7 AM to 4 PM, Pacic Time,
excluding holidays.
By submitting this paper application, you acknowledge and agree that:
If the above terms are not acceptable to you, please do not submit the application.
If you need to purchase the insurance urgently with a specic effective date, please call our
ofce at +1 (866) INSUBUY or the writing agent to conrm, before sending the application.
Back dated applications are not possible.
Requested effective date is not always guaranteed.
It does not matter when you send the application by postal mail, fax or
scanned copy in email.
It does not matter when the postal mail, fax or email was received by us, as
the underwriting department can consider the effective date only according
to when they review the application.
If there is any dispute between you and the underwriting department about
when the effective date should be, the decision of the underwriting department
will be nal.
You hold Insubuy and the writing agent (if any) harmless and relieve us from
any liability because of this.
Application For High Limit
Accidental Death Insurance
High Limit Accident - 10-15-2019©Petersen International Underwriters
Producer #:____________
Proposed Insured:
Personal Statistics:
Contact Information:
Residence Address:
Business Address:
Annual Income:
Requested Sum Insured:
Period of Insurance:
Policy Owner (If not the insured):
First _____________________________ Middle ___________________ Last _________________________________________
Date of Birth ______/_______/_________ Height __________________ Weight _________________ Gender qMale qFemale
Email ________________________________________ Telephone (______)_______-________ Fax (______)_______-________
Number & Street __________________________________________________________________________________________
City _______________________________ State______________________ Zip Code ___________________________________
___________________________________________ Employer:_____________________________________________________
Number & Street __________________________________________________________________________________________
City _______________________________ State______________________ Zip Code ___________________________________
US$ ________________________________________ Net Worth: US$_______________________________________________
Requested Eective Date _______________________ Expiry Date __________________________________________________
____________________________________________ Relationship __________________________________________________
____________________________________________ Relationship __________________________________________________
q 24 Hour
q Accidental Death (AD) or q Accidental Death & Dismemberment (AD&D)
Benets (Check one):
Coverage (Check one):
DECLARATION I declare that the above statements are true and complete, and that, apart from the matters declared above, I am in good health and ordinarily enjoy
good health. I agree to the Underwriters obtaining medical information from any doctor who has attended me and authorize such doctor to give this information. I agree
that this proposal shall form the basis of the contract should the insurance be eected and any misstatements above may be grounds for recision. I understand that pre-
existing conditions are not covered until a period of insurance of 12 months, treatment free, has elapsed.
Proposed Insured _________________________________Signature ________________________________________Date___________________
Policy Owner Signature (If other than the proposed Insured) ______________________________________________Date___________________
e following questions are to be answered by the proposed insured. If “Yes” is answered for any of the following questions please provide full
details in the space below.
1. Do you have any physical defect or inrmity?
2. Is your sight or hearing defective?
3. Have you suered from, been diagnosed with, received treatment for, or been prescribed treatment for any
condition related to any nervous or mental condition, fainting episode, blackout, t or paralysis of any kind?
4. Have you suered from, been diagnosed with, received treatment for, or been prescribed treatment for high
blood pressure, a heart condition, rheumatic fever or diabetes?
5. Have you suered from, been diagnosed with, received treatment for, or been prescribed treatment for a
slipped disc” or other spinal disorder, a hernia or any rheumatic or arthritic condition?
6. Have you ever been declined or accepted on special terms for life, accident or illness insurance?
7. Do you intend to engage in hazardous sports or any other pastimes that expose you to extra personal injury?
8. Will you be travelling outside of the USA?
9. Will any of your air travel be on private or chartered aircra?
10. Is there anything preventing you from working full-time in your occupation?
q Ye s q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
Question # Please provide detailed information for each question answered “Yes”
Insubuy®, Inc. 4200 Mapleshade Ln, Suite 200, Plano, TX 75093 | Phone: +1 (866) INSUBUY | Fax: (972) 767-4470 | info[at]insubuy.com
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