Fillable Form 1: Proposed Transamerica Life Insurance Company Primary

Fill Online, Printable, Fillable, Blank Form 1: Proposed Transamerica Life Insurance Company Primary Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 1: Proposed Transamerica Life Insurance Company Primary

On average this form takes 91 minutes to complete

The Form 1: Proposed Transamerica Life Insurance Company Primary form is 23 pages long and contains:

  • 0 signatures
  • 214 check-boxes
  • 263 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
T-AP-WL10FL-R0518
Page 1 of 19 Proposed Primary Insured
Transamerica Life Insurance Company
1
Proposed
Primary
Insured
Personal
Information
Legal First Name Middle Name Legal Last Name Sufx
City U.S. State / Territory
Zip Code Country Years at Address
Place of Birth (State / Territory, Country)
Physical Address (Cannot be a P.O. Box)
Apartment / Unit
Gender Marital Status
Male Female
Single Registered Domestic Partner
City U.S. State / Territory Zip Code
Mailing Address (If different from Physical Address)
U.S. Social Security Number
- -
Date of Birth (mm/dd/yyyy)
/ /
Individual Life Insurance Application
Unless otherwise stated, “You” refers to the Proposed Primary Insured.
U.S. Driver’s License Number U.S. State / Territory Expiration Date (mm/dd/yyyy)
Preferred Phone Number Alternate Phone Number
Best Time to Call Preferred method of communication
Email Address
Mobile Mobile
AM PM Mail Phone Email
Home Ofce: 4333 Edgewood Road NE Cedar Rapids, IA 52499
Time Zone
/ /
Occupation
Married (including common law)
Reset Form
T-AP-WL10FL-R0518
Page 2 of 19 Proposed Primary Insured
U.S Citizenship
2
Country of Citizenship
Are you a U.S. citizen?
Yes No
Green Card Number and Expiration
If yes, go to
next section.
United States
citizens and
valid Green
Card holders are
eligible.
Will the insurance applied for on your life discontinue, replace or change
any existing life or annuity coverage? If yes, please note the coverage to be
replaced in the table and complete the state required forms, if applicable.
Do you have any existing life insurance or annuities? If yes, please ll out the
table for all existing life/annuity coverage and complete the state required forms,
if applicable.
Yes No
3
Other Insurance
Type of Coverage: Personal, Business, Employer Provided, Group
If yes
Type of Coverage Company Policy # Face Amount Replacement?
Yes No
Yes No
Yes No
$
$
$
Yes No
If yes
If you are doing
an Internal
Replacement,
please ll
out the Full
Surrender form.
Is this intended to be a 1035 Exchange? If yes, please complete the 1035 supplement.
Anticipated Cash Value Transfer
Yes No
$
If yes
T-AP-WL10FL-R0518
Page 3 of 19 Proposed Primary Insured
4
Complete this section only if the owner is not the Proposed Primary
Insured.
Owner
Owner’s relationship to Proposed Primary Insured
Spouse Parent Domestic Partner
Child GrandParent Other
Country of Citizenship
Do you have
a Contingent
Owner?
If you have
a contingent
owner, complete
the Contingent
Owner
Supplement.
Is the owner a U.S. citizen?
Yes No
Green Card Number and Expiration (mm/dd/yyyy)
If yes, go to
next section.
Legal First Name Middle Name Legal Last Name Sufx
City U.S. State / Territory
Country Years at Address Preferred Phone Number
Physical Address (Cannot be a P.O. Box)
Apartment / Unit
City U.S. State / Territory Zip Code
Mailing Address (If different from Physical Address)
U.S. Social Security Number
- -
Date of Birth (mm/dd/yyyy)
/ /
/ /
Email Address
Gender
Male Female
Is the owner a Person or a Trust?
Person Trust - (go to the Trust questions below)
If person,
complete
through
Country of
Citizenship.
Zip Code
United States
citizens and
valid Green
Card holders are
eligible.
Complete this section only if the owner is a Trust.
Trust Original Trust Date (mm/dd/yyyy)
U.S. Tax ID Number
-
/ /
If owner
is a trust,
complete a
Trust
Certication.
Mobile
T-AP-WL10FL-R0518
Page 4 of 19 Proposed Primary Insured
5
Primary
Beneciaries
U.S. Tax ID Number (if a Business Entity or Trust)U.S. Social Security Number (if a person)
-
Legal First Name Middle Name Legal Last Name Sufx
Business Entity or Trust (if applicable) Date of Birth or Trust Date (mm/dd/yyyy)
/ /
- -
U.S. State / Territory Zip Code Phone Number
Mailing Address
City
Same as Proposed Primary Insured
Relationship to the Proposed Primary Insured
If beneciary is
a trust, please
complete a
Trust
Certication.
Primary
Beneciary 1
Percentage of
Death Benets
%
Total shares
between
all primary
beneciaries must
equal 100%.
Spouse Parent Grandparent Child Estate
Domestic Partner Trust Other _____________________
Continued on next page
T-AP-WL10FL-R0518
Page 5 of 19 Proposed Primary Insured
If beneciary is
a trust, please
complete a
Trust
Certication.
Total shares between all primary beneciaries must equal 100%.
5
Primary
Beneciaries
U.S. Tax ID Number (if a Business Entity or Trust)U.S. Social Security Number (if a person)
-
Legal First Name Middle Name Legal Last Name Sufx
Business Entity or Trust (if applicable) Date of Birth or Trust Date (mm/dd/yyyy)
Primary
Beneciary 2
Percentage of
Death Benets
%
/ /
- -
U.S. State / Territory Zip Code Phone Number
Mailing Address City
Same as Proposed Primary Insured
Total shares
between
all primary
beneciaries must
equal 100%.
Relationship to the Proposed Primary Insured
Spouse Parent Grandparent Child Estate
Domestic Partner Trust Other _____________________
U.S. Tax ID Number (if a Business Entity or Trust)U.S. Social Security Number (if a person)
-
Legal First Name Middle Name Legal Last Name Sufx
Business Entity or Trust (if applicable) Date of Birth or Trust Date (mm/dd/yyyy)
/ /
- -
U.S. State / Territory Zip Code Phone Number
Mailing Address City
Same as Proposed Primary Insured
Relationship to the Proposed Primary Insured
Spouse Parent Grandparent Child Estate
Domestic Partner Trust Other _____________________
If beneciary is
a trust, please
complete a
Trust
Certication.
Primary
Beneciary 3
Percentage of
Death Benets
%
Total shares
between
all primary
beneciaries must
equal 100%.
continued
If you need space for more primary beneciaries, complete the
Beneciary Supplement.
T-AP-WL10FL-R0518
Page 6 of 19 Proposed Primary Insured
6
Contingent
Beneciaries
U.S. Tax ID Number (if a Business Entity or Trust)U.S. Social Security Number (if a person)
-
Legal First Name Middle Name Legal Last Name Sufx
Business Entity or Trust (if applicable) Date of Birth or Trust Date (mm/dd/yyyy)
Contingent
Beneciary 1
Percentage of
Death Benets
%
/ /
- -
Mailing Address City
Same as Proposed Primary Insured
Total shares
between all
contingent
beneciaries must
equal 100%.
Total shares between all contingent beneciaries must equal 100%.
If you need space for more contingent beneciaries, complete the
Beneciary Supplement.
If beneciary
is a trust,
complete a
Trust
Certication.
U.S. State / Territory Zip Code Phone Number
Relationship to the Proposed Primary Insured
If beneciary
is a trust,
complete a
Trust
Certication.
U.S. Tax ID Number (if a Business Entity or Trust)U.S. Social Security Number (if a person)
-
Legal First Name Middle Name Legal Last Name Sufx
Business Entity or Trust (if applicable) Date of Birth or Trust Date (mm/dd/yyyy)
Contingent
Beneciary 2
Percentage of
Death Benets
%
/ /
- -
U.S. State / Territory Zip Code Phone Number
Mailing Address City
Same as Proposed Primary Insured
Total shares
between all
contingent
beneciaries must
equal 100%.
Relationship to the Proposed Primary Insured
Spouse Parent Grandparent Child Estate
Domestic Partner Trust Other _____________________
Spouse Parent Grandparent Child Estate
Domestic Partner Trust Other _____________________
T-AP-WL10FL-R0518
Page 7 of 19 Proposed Primary Insured
7
Secondary
Addressee
Complete this
section if you
would like to list an
additional person
to receive copies of
notices and letters
regarding possible
lapses in coverage.
Email Address
Mobile
Legal First Name Middle Name Legal Last Name Sufx
City U.S. State / Territory Zip Code
Mailing Address
Phone Number
Additional Benets (Not available with all products and not available
in all States)
Benet Amount
Coverage amount equal to policy
face amount
Accidental Death Benet Rider
Child/Grandchild Rider
8
Product Details
Rate Class Applied for:
Preferred Non-Tobacco Preferred Tobacco Preferred Juvenile
Standard Non-Tobacco Standard Tobacco Standard Juvenile
Graded
Product Name Coverage Amount
$
If a policy cannot be issued as applied for, would you accept a rated policy if available?
This is the amount of
life insurance coverage
you are applying for.
Yes No
$
Complete
the Child/
Grandchild
Rider
Supplement
Application
Automatic Premium Loan (may not be available on all policies).
Elect Do Not Elect
Adjust face amount to premium?
Yes No
If yes
T-AP-WL10FL-R0518
Page 8 of 19 Proposed Primary Insured
If the initial
draft date is
prior to the
application
date, please
complete the
Back Date
to Save Age
Form.
9
Premium
Total Premium
$
If you select an initial premium draft date in the future, it may not be greater than 30 days
after the application date. If you select an initial premium draft date in the future, you will
not have potential coverage until that date under the Conditional Receipt.
Recurring Payment Frequency
Monthly Quarterly Semi-Annually Annually
Initial Draft Date (MM/DD) 1st thru 28th only
/
Current Date
For EFT, please complete the
Electronic Payment Form.
For Social Security Benets Billing,
please complete the Social Security
Benets Billing Form.
Initial
Recurring
Payment Option Initial / Recurring Form Information
Initial
Recurring
Initial
Recurring
Initial
Recurring
Social Security
Billing Benets
Check
1035 Exchange
EFT
For monthly, please complete the
Electronic Payment form for recurring
payments.
For 1035 Exchange, please complete
the 1035 Exchange Form.
10
Premium
Payor
City U.S. State / Territory
Zip Code Country
Physical Address (Cannot be a P.O. Box)
Apartment / Unit
Phone Number
Mobile
Complete this section if the premium payor is different than the owner.
A person or
Trust paying
the premium
Legal First Name Middle Name Legal Last Name Sufx
U.S. Social Security Number
- -
Date of Birth (mm/dd/yyyy)
/ /
Trust
U.S. Tax ID Number
-
Continued on next page
T-AP-WL10FL-R0518
Page 9 of 19 Proposed Primary Insured
10
Premium
Payor
Email Address
Premium Payor’s relationship if other than the Proposed Insured
Spouse Child Domestic Partner Other _____________________
Parent Trust Grandparent
continued
Country of Citizenship
Are you a U.S. citizen?
Yes No
Green Card Number and Expiration
If yes, go to
next section.
United States
citizens and
valid Green
Card holders are
eligible.
11
Primary Care
Physician
Address
Physician, Hospital or Health Care Provider Name Phone Number
Date of last visit (mm/dd/yyyy)
/ /
B. Height (feet and inches) C. Current Weight (pounds)
’ ”
D. Approximate weight a year ago (pounds)
1-14 lbs. more than current 1-14 lbs. less than current Same as current
15 lbs. more than current 15 lbs. less than current
F. Explain your weight gain or loss of greater than 15 lbs in the last year. Check all that
apply.
Diet Lifestyle Change Other __________________________
Exercise Illness
E. If your weight gain or loss is greater than 15 lbs in the last year, what is the difference in
pounds?
pounds
If 15 lbs.
more or
less, proceed
to the
following two
questions.
12
Lifestyle
A. Within the last 12 months have you used nicotine replacement, smoking or tobacco
products in any form including, but not limited to the following: nicotine gum, patch or
pills; cigarettes; cigars; pipe; chew; snuff; e-cigarettes; vape; hookah; or have you used
marijuana more than 12 times in the last 12 months?
Yes No
Check this
box if you do
not have a
physician.
T-AP-WL10FL-R0518
Page 10 of 19 Proposed Primary Insured
13
Medical
History
Part 1
Have you had, been diagnosed with, treated for, tested positive for or been given medical
advice by a licensed member of the medical profession for any of the following:
Yes No
A. Currently under the age of 18 with autism, depression, bipolar disorder or schizophrenia?
Yes No
B. Prior to the age of 45 with Heart Failure or Congestive Heart Failure?
Yes No
C. Are you currently hospitalized, bedridden, residing in a nursing home, assisted or long
term care facility, receiving hospice or home health care; or been advised or planning to
have surgery requiring general anesthesia?
Home Health Care is dened as: Medical care provided by a medical professional, friends or
family member including, but not limited to arranging medications, taking blood pressure or
sugar readings, administering medications, wound care, feeding tube, etc.
Yes No
D. Have you ever been diagnosed by a licensed member of the medical profession
or tested positive for Acquired Immune Deciency Syndrome (AIDS), Human
Immunodeciency Virus (HIV) or tested positive on an AIDS/HIV-related test?
Yes No
Yes No
Have you ever had, been diagnosed with, treated for, tested positive for or been given
medical advice by a licensed member of the medical profession for any of the following:
F. Alzheimer’s, dementia, memory loss, mental incapacity, Lou Gehrig’s disease (ALS),
Downs Syndrome, Huntington’s disease, sickle cell anemia, cystic fibrosis, pulmonary
brosis, cerebral palsy or been diagnosed by a medical professional as having a terminal
medical condition that is expected to result in death within the next 18 months?
G. Diabetic coma?
H. Amputation other than at the time of an accident or trauma?
Yes No
I. Metastatic cancer, recurrent cancer, multiple cancers or cancer with lymph node involvement?
Yes No
Yes No
E. Have you ever
been the recipient or been given medical advice by a licensed member
of the medical profession to be a recipient of stem-cell, tissue, bone marrow, or organ
transplant (other than corneal)?
T-AP-WL10FL-R0518
Page 11 of 19 Proposed Primary Insured
13
Medical
History
Part 1
During the last 2 years have you had, been diagnosed with, treated for, tested positive for
or been given medical advice by a licensed member of the medical profession for any of the
following:
Yes No
J. Cancer (other than basal cell carcinoma)?
Yes No
K. Had testing by a medical professional for which the results have not been received,
been non-compliant with physician orders regarding treatment plans, or been advised
to have any diagnostic testing (other than for routine screening purposes), treatment,
hospitalization or other procedure that has not been done?
During the last 2 years have you:
Yes No
Yes No
L. Attempted suicide; been incarcerated, on probation, on parole, or convicted of or
awaiting trial for a felony?
M. Been convicted for or plead no contest to reckless driving or operating while
intoxicated (DWI/OWI/DUI) or had 3 or more moving violations?
If all questions in Part 1 are answered “No,” proceed to Part 2.
If any question in Part 1 is answered “Yes”, you are not eligible for any
coverage.
continued
T-AP-WL10FL-R0518
Page 12 of 19 Proposed Primary Insured
14
Medical
History
Part 2
Have you had, been diagnosed with, treated for, tested positive for or been given medical
advice by a licensed member of the medical profession for any of the following:
Yes No
Yes No
F. During the last 4 years have you had, been diagnosed with, treated for, tested positive
for or been given medical advice by a licensed member of the medical profession for cancer
(other than basal cell carcinoma)?
A. Prior to the age of 20 with Diabetes (other than gestational diabetes)?
Yes No
B. Prior to the age of 26 with Crohn’s Disease?
Yes No
C. Prior to the age of 45 with Parkinson’s Disease; Coronary Artery Disease, Peripheral
Vascular Disease, or Cerebral Vascular Disease; Heart Attack, Transient Ischemic Attack
(TIA), or Stroke; Cardiac Surgery, Bypass Surgery, Stent Implant, Angioplasty, Pacemaker
or Debrillator Implant, or Heart Valve Replacement?
Yes No
D. Cirrhosis, heart failure, or congestive heart failure (CHF); or an aneurysm that has not
been surgically corrected (still present)?
Have you ever had, been diagnosed with, treated for, tested positive for or been given
medical advice by a licensed member of the medical profession for any of the following:
Yes No
E. Hepatitis C?
E2. If cured, when was the last blood test (RNA PCR Titer)
showing the Hepatitis C was cured?
0-24 months after treatment ended
More than 24 months after treatment ended
E1. Has the Hepatitis C been cured?
Cured Not Cured
If yes, proceed
to E1 & E2.
If the answer to E2 is 0-24 months, then the best rate class is Graded. If the answer is
more than 24 months, then the best rate class is Standard and the answer counts as a
“No” when referring to directions below.
G. During the last 2 years have you used illegal drugs or had, been diagnosed with, treated
for, tested positive for or been given medical advice by a licensed member of the medical
profession for alcoholism, alcohol use/abuse, drug use/abuse (including prescription drugs),
muscular dystrophy, or systemic lupus erythematosus (SLE)?
Yes No
If SLE has been in remission and there has been no treatment for more than two years, you
may then answer this question “No” in regard to only the SLE.
T-AP-WL10FL-R0518
Page 13 of 19 Proposed Primary Insured
14
Medical
History
Part 2
continued
During the last 2 years have you:
Yes No
H. Required assistance with activities of daily living (ADL’s) such as bathing, dressing, eating,
toileting, getting in and out of chair or bed, or do you have ongoing neurological incontinence
or, has a medical professional recommended that you be conned to a Nursing Home?
Yes No
I. Used a wheelchair, electric
scooter or electric cart?
If yes, proceed
to I1.
During the last 1 year have you had, been diagnosed with, treated for, tested positive for or been
given medical advice by a licensed member of the medical profession for any of the following:
Yes No
J. More than 6 seizures; or had, been diagnosed with, been treated for or advised to
receive treatment for any liver disease (including but not limited to autoimmune hepatitis)
other than cirrhosis or Hepatitis C that should have been noted in a prior question?
Yes No
K. Heart attack, stroke (CVA) or transient ischemic attack (TIA)?
Yes No
L. Used oxygen to assist in breathing (including for Sleep Apnea); received kidney dialysis;
kidney failure or chronic kidney disease (stage 4 or 5); encephalitis; or have you been
unemployed or disabled and had, been diagnosed with, treated for or been given medical
advice by a licensed member of the medical profession for chronic pain?
Currently use or use occasionally at facilities such as,
but not limited to, the grocery store, department stores,
warehouse stores, airports
Reason for use is expected to resolve in the next 3
months or the reason for use has resolved
I1. If yes, provide details regarding use:
If the answer to I1 is “Reason for use...”, count I as a “No” when referring to directions below.
M. Angina (chest pain); or had or been
advised to have heart surgery of any kind
including bypass surgery, angioplasty,
stent implant or pacemaker implant; or
had an aneurysm surgically corrected?
M1. When was the angina (chest pain)
rst diagnosed?
Yes No
0-12 months ago
13-24 months ago
Greater than 24 months ago
If yes for angina,
proceed to M1.
If all questions in Part 2 are answered “No,” proceed to Part 3.
If one question in Part 2 is answered “Yes,” you are potentially eligible
for the Graded Death Benet product.
If two or more questions in Part 2 are answered “Yes,” you are not
eligible for any coverage.
If the answer to M1 is 0-12 months, then the best rate class is Graded. If the answer is
13-24 months, then the best rate class is Standard. If the answer is greater than 24
months, count M as a “No” when referring to directions below.
Chronic Pain is dened as: Pain lasting more than 6 months or requiring 6 or more lls of
narcotic pain prescriptions in any 12 month period.
T-AP-WL10FL-R0518
Page 14 of 19 Proposed Primary Insured
15
Medical
History
Part 3
Yes No
Yes No
Have you ever had, been diagnosed with, treated for, tested positive for or been given
medical advice by a licensed member of the medical profession for any of the following:
A. Prior to the age of 45, have you had, been diagnosed with, treated for, tested positive
for or been given medical advice by a licensed member of the medical profession for cancer
(other than Basal Cell)?
During the last 2 years have you had, been diagnosed with, treated for, tested positive for
or been given medical advice by a licensed member of the medical profession for any of the
following:
During the last 4 years have you had, been diagnosed with, treated for, tested positive for
or been given medical advice by a licensed member of the medical profession for any of the
following:
C. Parkinson’s disease, multiple sclerosis, systemic lupus erythematosus (SLE), sarcoidosis,
Crohn’s disease, ulcerative colitis, chronic obstructive pulmonary disease (COPD) including
emphysema, chronic asthma, black lung or other chronic respiratory disease?
Yes No
B. Bipolar disorder or schizophrenia?
Yes No
D. Kidney disease (stage 1, 2 or 3) or other kidney disorder?
Yes No
F. Been convicted for or plead no contest to reckless driving or operating while
intoxicated (DWI/OWI/DUI) or had 3 or more moving violations?
Yes No
G. Heart attack, stroke (CVA) or transient ischemic attack (TIA)?
Yes No
H. Used insulin; had more than 6 seizures; spina bida cystica, pancreatitis, tuberculosis;
hepatitis B or other liver disease?
During the last 4 years have you:
Chronic Asthma is dened as: Using inhalers year round on a daily or weekly basis, or lling
prescriptions 6 or more times in any 12 month period.
Yes No
E. Used illegal drugs; alcoholism, alcohol use/abuse, drug use/abuse, (including
prescription drugs)?
T-AP-WL10FL-R0518
Page 15 of 19 Proposed Primary Insured
15
Medical
History
Part 3
continued
During the last 2 years have you had, been diagnosed with, treated for, tested positive for
or been given medical advice by a licensed member of the medical profession for any of the
following:
If all questions in Part 3 are answered “No,” you are potentially eligible
for the Preferred product.
If one question in Part 3 is answered “Yes,” you are potentially eligible
for the Standard product.
If two or more questions in Part 3 are answered “Yes,” you are
potentially eligible for the Graded Death Benet product.
I. Angina (chest pain); cardiomyopathy;
vascular, circulatory or blood disorder
(including anemia other than iron
deciency); heart surgery of any kind
including bypass surgery, angioplasty,
stent implant; irregular heart rhythm
such as atrial brillation or heart murmur;
had an aneurysm surgically corrected;
or do you currently have a pacemaker/
debrillator?
I1. When was the angina (chest pain)
rst diagnosed?
Yes No
0-12 months ago
13-24 months ago
Greater than 24 months ago
If the answer to I1 is 0-12 months, then the best rate class is Graded. If the answer is
13-24 months, then the best rate class is Standard. If the answer is greater than 24
months, count I as a “No” when referring to directions below.
If yes for angina,
proceed to I1.
T-AP-WL10FL-R0518
Page 16 of 19 Proposed Primary Insured
16
Authorization to Obtain and Disclose Information
Each of the undersigned hereby certies and represents as follows:
The statements and answers given on this application are true and
complete to the best of my knowledge and belief. I acknowledge and
agree (A) this application shall consist of the Individual Life Insurance
Application, and any required application supplement(s)/amendment(s),
and shall be the basis for any contract issued on this application; (B)
that the Agent does not have the authority to waive any question on
this application, to decide if insurance will be issued, or to modify any
term or provision of any insurance which may be issued based on this
application, only a writing signed by an ofcer of the Company can
change the terms of this application or the terms of any insurance
issued by the Company; (C) except as provided in the Conditional
Receipt, if issued with the same Insured(s) as on this application,
no policy applied for shall take effect until after all of the following
conditions have been met: 1) the minimum initial premium must be
received by the Company; 2) the Owner must have personally received
and accepted the policy during the lifetime of each Insured and there
must have been no change in the insurability of any Insured; and 3) on
the date of the later of either 1) or 2) above, all of the statements and
answers given in this application must be true and complete. Unless
otherwise stated the undersigned Insured is the premium payor and
Owner of the policy applied for.
I hereby authorize any licensed physician, medical practitioner, hospital,
clinic or other medical or medically related facility, wellness/tness,
nancial services or insurance company, MIB, Inc. (“MIB”), consumer
reporting agency, data aggregator, or any other organization, institution
or person, that has any records or knowledge of me or my health/
tness, nances, credit history, credit standing, credit capacity, life
activities or purchase history, to give to the Company, or its reinsurers,
any such information. I authorize the Company, or its reinsurers,
to make a brief report of my personal health information to MIB. A
photographic copy of this authorization shall be as valid as the original.
I understand a credit report may be requested in connection with
this authorization. I also understand that any credit reporting agency
contacted in connection with this authorization may retain and use
any information provided about me to the credit reporting agency to
the extent that the information is in addition to or more current than
the information currently held by such credit reporting agency, and do
consent to such use of my information.
I hereby expressly consent to receive calls about my application from
the Company or its representatives that involve the use of an automatic
telephone dialing system and/or an articial or prerecorded voice.
This authorization will be valid for 24 months, or the period permitted
by applicable law in the state where the policy is delivered or issued
for delivery, if shorter. Information released shall comply with the time
limit, if any, permitted by applicable law in the state where the policy
is delivered or issued for delivery. I understand that I may revoke it
at any time by giving written notice to the Company at the above
address. 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 benets, 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 database if such codes are reported by the Company
(or the Company becomes obligated to report such codes to MIB)
while this authorization is in-force. I understand the Company may use
the information collected via this authorization: (1) to underwrite my
insurance application, (2) to support the operations of the Company’s
business, (including performing actuarial or internal business studies,
research and analytics and other analysis), or (3) if a policy is issued,
to evaluate contestability and eligibility for benets, the policy’s
continuation or replacement, the policy’s reinstatement, or to contest a
claim under the policy.
The Company shall have 60 days from the date hereof within which to
consider and act on this application and if within such period a policy
has not been received by the Owner or if notice of approval or rejection
has not been given, then this application shall be deemed to have been
declined by the Company.
I acknowledge receipt of the Notice of Disclosure for (1) Notice to
Persons Applying for Insurance Regarding Investigative Report,
(2) MIB Pre-Notication, and (3) Notice of Insurance Information
Practices.
I understand that any omissions or misstatements in this
application could cause an otherwise valid claim to be denied
under any insurance issued from this application.
TAXPAYER IDENTIFICATION CERTIFICATION
Under current federal tax laws, the Company is required to obtain your Taxpayer Identication Number (e.g., a social security or employer
identication number, or “TIN”) and certication that you are not subject to backup withholding. Please review the following certication and
sign accordingly.
Under penalties of perjury, I certify that (1) the TIN listed in this application is my correct TIN; (2) I have not been notied that I am subject
to backup withholding, or the IRS has notied me I am no longer subject to backup withholding, or I am not subject to backup withholding
because I am exempt; and (3) I am a U.S. Person (U.S. citizen/legal resident). If not a U.S. Person, I have completed the appropriate Form
W-8BEN. The IRS does not require your consent to any provision of this form other than this certication. You must cross out item (2) if you
are currently subject to backup withholding.
T-AP-WL10FL-R0518
Page 17 of 19 Proposed Primary Insured
16
17
Authorization
to Obtain and
Disclose
Information
Other Insurance
(to be completed
by the Agent)
FRAUD WARNING: Any person who knowingly and with intent to injure, defraud, or
deceive any insurer les a statement of claim or an application containing any false,
incomplete, or misleading information is guilty of a felony of the third degree.
Signature of Proposed
Insured
Date (mm/dd/yyyy) City U.S. State / Territory
Title of Trust
(If owner is trust)
continued
Agent Signature
Does the Proposed Insured have existing life insurance policies or annuity contracts with
the company or any other company?
Yes No
If replacement of existing insurance is involved, have you complied with all state
requirements, including any Disclosure and Comparison Statements? If no, explain.
Yes No
Will the policy applied for discontinue, replace or change any existing life insurance policy
or annuity?
Yes No
I certify that I used only company approved sales materials and copies of all sales
materials used during the solicitation were provided to the applicant.
Signature of Parent
or Legal Guardian
(Of children under age 18)
Date (mm/dd/yyyy) City U.S. State / Territory
Signature of Applicant/Owner
(If other than Proposed Insured)
Date (mm/dd/yyyy) City U.S. State / Territory
/ /
/ /
/ /
Explain
Trustee Last NameTrustee First Name
Print Agent 2 Name Agent 2 Signature Agent 2 Number Florida License ID#
Print Agent 1 Name Agent 1 SignatureAgent 1 Number Florida License ID#
T-AP-WL10FL-R0518
Page 18 of 19 Proposed Primary Insured
NOTICE OF DISCLOSURE
NOTICE TO PERSONS APPLYING FOR INSURANCE
REGARDING INVESTIGATIVE REPORT
To proposed Insured: In connection with this application, an investigative consumer report may be prepared about you. Such
reports are part of the process of evaluating risks for life and health insurance. Typically, this report will contain information
about your character, general reputation, personal characteristics and mode of living. The information in the report may be
obtained by talking with you or members of your family, business associates, nancial sources, neighbors, and others
you know. You may ask to be interviewed in connection with the preparation of any such report. Also, we may have the
report updated if you apply for more coverage.
Upon your written request, we will let you know whether a report was prepared and we will give you the name,
address, and telephone number of the agency preparing the report. By contacting that agency and providing proper
identication, you may obtain a copy of the report.
MIB GROUP, INC. (MIB) PRE-NOTIFICATION
Proposed Insured and other persons proposed to be insured, if any: Information regarding your insurability will be
treated as condential. The Company or its reinsurers may, however, make a brief report thereon to MIB, Inc., a
not-for-prot membership organization of insurance companies, which operates an information exchange on behalf of its
Members. If you apply to another MIB Member company for life or health insurance coverage, or a claim for benets is
submitted to such a company, MIB, upon request, will supply such company with the information in its le.
Upon receipt of a request from you MIB will arrange disclosure of any information it may have in your le. Please contact
MIB at 866-692-6901 (TTY 866-346-3642). If you question the accuracy of information in MIB’s le, you may contact MIB
and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act (www.ftc.gov).
The address of MIB’s information ofce is 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734.
The Company, or its reinsurers, may also release information in its le to other insurance companies to whom you may
apply for life or health insurance, or to whom a claim for benets may be submitted. Information for consumers about MIB
may be obtained on its website at www.mib.com.
NOTICE OF INSURANCE INFORMATION PRACTICES
To proposed Insured: Personal information may be collected from persons other than the individual(s) proposed for coverage.
Such information as well as other personal or privileged information subsequently collected by us or our Agent may in certain
circumstances be disclosed to third parties without authorization. Upon request, you have the right to access your personal
information and ask for corrections. You may obtain a complete description of our Information Practices by writing to
Transamerica Life Insurance Company, Attn: Director of Underwriting, [4333 Edgewood Road NE, Cedar Rapids, Iowa 52499.]
Please provide a copy of these notices to the applicant and to any proposed
Insureds not living in the household.
T-AP-WL10FL-R0518
Page 19 of 19
CONDITIONAL RECEIPT
No coverage will be effective prior to delivery of the policy applied for unless and until all the following conditions are met:
Conditions of Coverage
1. On the Effective Date indicated below, the state of health and all factors affecting insurability of each person proposed
for coverage must be stated in the application required by the Company and the application must not contain a material
misrepresentation;
2. An amount equal to the rst full premium required must be paid and any check, Authorization for Electronic Funds
Transfer (EFT), payroll deduction or allotment given in payment must be honored when rst presented; and,
3. Each person proposed for coverage is on the Effective Date insurable and acceptable to the Company under its rules,
limits and underwriting standards for the plan and for the amount applied for, without modication of plan, premium rates
or amount of coverage.
Effective Date
If all of the above conditions are met, insurance in the amount applied for or $50,000, whichever is lower, will become effective
on the date the application is completed. If any of the above conditions are not met, or if the proposed Insured dies prior
to a future date selected for draft of the initial premium or if the proposed Insured dies by suicide, this receipt provides no
coverage, and the liability of the Company is the return of the amount remitted with this receipt. Coverage which takes effect
through this receipt will terminate at the EARLIEST of the following: (a) the effective date of the policy; (b) thirty (30) days after
the date of the application; (c) three (3) days after the date the Company sends written notice that the receipt is terminated.
Please provide a copy of these notices to the applicant and to any proposed
Insureds not living in the household.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 1: Proposed Transamerica Life Insurance Company Primary

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 5 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document