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Life Insurance
Application
2416 Sir Barton Way Suite 110 Lexington KY, 40509
1-800-888-6542
App 1 (09/17)
Page 1 of 4
MOUNTAIN LIFE INSURANCE COMPANY
2416 Sir Barton Way Suite 110 Lexington, KY 40509
1-800-888-6542
Application for Life Insurance – Part I
Proposed Insured
Name (First, Middle, Last) Birth Date Age Place of Birth Gender Social Security No.
Home Address (Street) (City) (State) (Zip)
Occupation Marital Status Driver’s Lic. No. & State Home Phone No. Work Phone No.
Former Address (if moved last 3 years):
Employer’s Name Employer’s Address Years Employed
Applicant (Owner) if other than Proposed Insured (Owner must sign Page 3) Home Phone No.
*If Payor is other than Owner, furnish information in Remarks on Page 3. Work Phone No.
Owner Name (If Trust, include date of Trust) Relationship Soc. Sec. No. or Tax I.D. No.
Address (Street) (City) (State) (Zip)
For All beneficiary designations: If multiple beneficiaries named, shares will be divided equally among the surviving beneficiaries,
unless other specified.
Primary Beneficiary
Relationship
%
Contingent Beneficiary
Relationship
%
Premium with Application $
Annual Semi-Annual Quarterly Monthly (EFT Only)
How Paid: Direct Bill Electronic Funds Transfer (Monthly Direct Bill Not Available) Other
Mail Premium Notice To: (If other than proposed insured)
Amount of Insurance $ Plan of Insurance Plan No.
Preferred Standard Tobacco
Additional Benefits:
Waiver of Premium Benefit Rider Spouse Rider $
Automatic Premium Loan
Accidental Death Benefit Rider $
Guaranteed Insurability Benefit Rider $
Children’s Rider $ Other
Regarding Proposed Insured: (If any “yes”, explain and give name of every Company. Use Remarks section if additional space is needed.)
YES
NO
(a) Is the Policy applied for to replace or change any existing insurance or annuities in this or any other Company?
Indicate in space below (If “yes”, check which policy and complete replacement forms, if required.)
(b) Does proposed insured have an application pending with another Company? (If “yes”, give Company
and Amount below.)
(c) Has proposed insured ever been rated, declined or postponed for life or health insurance coverage?
(d) Is there life insurance in force on the proposed insured’s life? List policies below and include insurance whether
owned by the insured or not.
Company
Policy
Replace or
Purpose
Issue
Number
Change?
Bus./Pers.
Date
App 1 (09/17)
Page 2 of 4
(Continuation of Application)
Please answer all of the following questions:
1.
Height
Weight
Weight Gain or Loss in Past Year? Yes No lbs. Reason
YES NO
mm/dd/yyyy
2.
Within the past 10 years has the proposed insured been treated or diagnosed by a physician as having:
(Circle conditions to which a “yes” answer applies and give details in number 5 below.)
(a)
Disorder of brain or spinal cord, paralysis, mental disorder, epilepsy, stroke, convulsions, chronic
headaches, or received counseling for anxiety, depression or any other emotional condition?
(b)
Asthma, bronchitis, emphysema, tuberculosis or other disorder of the lungs or respiratory system?
(c)
High or low blood pressure, heart disease, heart murmur, chest pain, palpitations, heart failure or
other disorder of the heart or circulatory system?
(d)
Any disorder of the esophagus, stomach, intestines, liver, pancreas or gall bladder?
(e)
Cancer, tumor, melanoma, lymphoma or disorder of the prostate, testes, breast, uterus, ovaries or
complication of pregnancy?
(f)
Arthritis, osteoporosis or other disorder of the muscles, skin or bones including joints or spine?
(g)
Diabetes, Sugar or blood in the urine, recurrent infections, enlarged lymph glands, anemia, excess
fatigue or other disorders of the glandular or blood systems?
(h)
Nephritis, Kidney stones or any disease of kidney or bladder?
(i)
Been told or diagnosed by a physician as having Acquired Immune Deficiency Syndrome (AIDS) or
“AIDS” related complex (ARC) or “AIDS” related condition?
(j)
Tested positive for antibodies to the “AIDS” (Human T-Cell Lymphotropic, Type III, HTLV-III) Virus,
or Lymphadenopathy Associated Virus (LAV)?
(k)
State the specific date of last medical consultation.
(l)
Name of Personal Physician
Address of Personal Physician
Reason for Treatment
3.
Has the proposed insured: (Circle conditions to which a “yes” answer applies and give details in Number 5 below.)
(a)
Other than above, had examination, treatment or consultation with a physician during the past
5 years?
(b)
Been on, or advised to be on any medication or prescribed diet?
(c)
Sought or been advised to seek advice or treatment for the use of drugs or alcohol?
(d)
Ever used narcotics, sedatives, depressants, stimulants or hallucinogens, other than under a doctor’s
prescription and direction?
(e)
Ever used marijuana, cocaine, or any illegal drug or been arrested for the possession of drugs?
(f)
Ever been or is currently a member of any alcohol or drug rehabilitation program?
(g)
Ever attempted suicide?
(h)
Had a parent, brother, or sister who had and/or died from cancer, diabetes, stroke, heart or kidney
disease, or who committed suicide? (Please show age of onset and/or age death occurred.)
4.
List all medications Proposed Insured is currently taking or has taken in the last 30 days.
5. Question
Number
Date of
Diagnosis
Diagnosis and
Medication Prescribed
Full Name, Complete Address and
Phone No. of Attending Physician or Hospital
Use Remarks section if additional space is needed.
6. During the past 2 years, has Proposed Insured: (Use Remarks section for “Yes” answers, if needed)
a. Made or contemplated making flights as pilot, student pilot or crew member?
(If “yes,” complete Aviation Questionnaire)
b. Participated in Sky Diving, Scuba Diving, organized Motor Vehicle Racing, or Mountain Climbing,
or intends to do so in the next 2 years? (If yes, complete Avocation Questionnaire)
c. Been convicted of driving while impaired or intoxicated, reckless driving, or 3 or more speeding violations?
d. Been arrested for other than a misdemeanor?
App 1 (09/17)
Page 3 of 4
(Continuation of Application)
e.
Made a claim for benefits to any insurance company or to the Veterans Administration because of
an illness or injury?
f.
Is Proposed Insured a US Citizen? (If no, provide copy of visa and/or green card, and include current
immigration status, expiration date, visa type and how long the Proposed Insured has been residing
in the U.S.)
g.
Is Proposed Insured planning to travel outside the US, Puerto Rico or Canada? (If yes, complete
Foreign Travel Questionnaire.)
YES NO
7. Has Proposed Insured used tobacco in any form within the last 24 months? (If so, explain)
8. Is Proposed Insured a member of, applied to be member of, or received notice of required service in
the Armed Forces, Reserves or National Guard?
9. In the last 5 years has Proposed Insured filed for bankruptcy?
REMARKS: (Details of “Yes” Answers)
Home Office Endorsement:
IT IS UNDERSTOOD AND AGREED: (1) That all answers to the questions on pages 1, 2 and 3 of this application are complete and
true to the best of my knowledge and/or belief. (2) That all answers to such questions, together with this agreement, shall form the
basis and become a part of any policy issued. (3) In consideration of the application and premium payment, insurance benefits
applied for shall take effect on the date of the application subject to terms and limitations of the Conditional Receipt; otherwise,
benefits shall not take effect until the policy is delivered to the owner and the first premium paid during the lifetime and continued
insurability, as stated in the application, of the person to be insured. (4) That acceptance of any policy issued on this application will
constitute a ratification of any correction in or addition to this application made by the Company and noted in the space for Home
Office Endorsement; however, no change shall be made as to amount, classification, plan of insurance or benefits unless agreed to in
writing. (5) Only the President or Secretary of the Company can make, modify, alter or discharge contracts or waive any of the
Company’s rights or requirements.
THE AGENT AND I CERT
IFY that I have read, or the agent has read to me, the completed application. I realize that any false
statement or misrepresentation in my application may result in loss of coverage under the policy (subject to the incontestability
provision, time limit on certain defenses, and legal proceedings).
Signed at this day of , 20
I certify information supplied by the applicant has been
accurately recorded on the application.
(Signature of Proposed Insured) (Agent’s Signature) (Agency & Agent Codes)
(Signature of Owner/Applicant – If Other Than Proposed Insured) (Agent’s Name – Please Print)
FRAUD WARNING – AL Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any
combination thereof.
FRAUD WARNING – AR Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
FRAUD WARNING – TN Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
App 1 (09/17)
Page 4 of 4
(Continuation of Application)
AGENT’S REPORT FOR LIFE AND DISABILITY
1. If required, did you arrange? Yes
Exam EKG
Blood Profile
Examiner Name:
No
Specimen
7.
a. Is the Proposed Insured a dependent? Yes No
If so, how much insurance do the parents carry?
$
b.
If the applicant is other than the parents, give name,
occupation and amount of insurance in force
c.
Are brothers and sisters insured for a like amount?
Yes No If no, please explain
d.
If the Proposed Insured is married, how much insurance
does the spouse carry? $
2. How long and how well have you known the Proposed
Insured? (If related, explain)
3. Did you see the Proposed Insured?
If no, please explain
Yes No
8. I have removed and presented the NOTICE OF INSURANCE
INFORMATION PRACTICES to Applicant/Insured.
Yes No
4. What is estimated annual income $ and
Net worth $ of the Proposed Insured?
What is the purpose of this insurance?
9. Does Proposed Insured have other Mountain Life
Insurance in force? Yes No
I
f “yes,” please list)
5. To the best of your knowledge, will the insurance applied
for replace any existing insurance? Yes No
Is this a 1035 exchange? Yes No
10. OTHER INFORMATION:
6.
IF APPLICATION IS FOR BUSINESS INSURANCE:
a.
Purpose of this insurance:
Keyman Fund a buy-sell agreement
Split Dollar Stock Redemption
Deferred Compensation Other
b.
Is firm:
Sole Proprietorship Partnership Corporation
c.
If Partnership, give names of partners:
d.
If Corporation, percentage of stock owned by Proposed
Insured:
e.
Net worth of Business $
f.
Amount of insurance in force or contemplated on other
members of firm: $
11.
Agent’s Signature Date
NOTICE OF INSURANCE INFORMATION PRACTICES
THIS NOTICE MUST BE GIVEN TO THE PROPOSED INSURED
NOTICE TO APPLICANT – PART 1. Pursuant to Public Law 91-508, notice is hereby given that as a part of our normal procedure for
processing your application, an investigative consumer report may be obtained whereby information is secured through personal interviews
with your friends, neighbors, and others with whom you are acquainted. This report, if obtained, typically contains information as to your
character, general reputation, personal characteristics and mode of living. You have the right to make a written request within a reasonable
period of time to receive additional detailed information concerning the nature and scope of this report. Please address your request to
Mountain Life Insurance Company, 2416 Sir Barton Way Suite 110, Lexington, KY 40509. These reports are obtained in your best interest.
They assist us in determining that Mountain Life's insured's meet certain standards, thus allowing us to continue offering coverage at the
lowest possible cost to all who qualify.
NOTICE
TO
APPLICANT
–
PART
2
.
Information regarding your insurability will be treated as confidential. Mountain Life Insurance Company
or its reinsurers may, however, make a brief report, including protected health information, to MIB, Inc., formerly known
as Medical Information Bureau, a not-for-profit 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 benefits is
submitted to such a company, MIB, upon request, will supply such company with the information about you in its file.
Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your file. If you question the
accuracy of information in the MIB file, you may contact MIB and seek correction in accordance with the procedures set forth in the
Federal Fair Credit Reporting Act. The address of the MIB information office is 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-
8734. The MIB phone number is 866-692-6901.
Mountain Life Insurance Company or its reinsurers may also make information in its files, including protected health information, available
to other life insurance companies to whom you apply for life or health insurance, or to whom you submit a claim for benefits. Information for
consumers about MIB may be obtained on it's website at www.mib.com.
CONDITIONAL RECEIPT
No insurance will become effective prior to policy delivery until each and every condition contained in this receipt is met.
Received from Date the sum of $ in
connection with an application for life insurance, bearing the same date as this receipt on the life of:
.
THE CONDITIONS under which insurance will become effective prior to policy delivery are as follows:
1. The amount of payment taken with the application must be not less than the full first premium according to the mode of premium payment
selected.
2. Any medical examinations and tests required by the Company must be completed within 45 days of the date of the application.
3. The Proposed Insured must be, on the Effective Date as defined below, a risk acceptable to the Company under its rules, standards and
practices for the exact policy and premium applied for, without any modification.
If each and every one of the above conditions have been fulfilled exactly, then insurance as provided by the terms and conditions of the policy
applied for will become effective as of the Effective Date, except that the total life insurance in force with the Company on the life of the Proposed
Insured, including this amount now applied for shall not exceed:
1. The amount of insurance requested in the application if such amount is less than that specified below; otherwise
2. $100,000 if Proposed Insured is within ages 21 through 65; or
3. $25,000 at all other ages.
“Age” as used herein means age at last birth date.
“Effective Date” as used herein means the latest of:
1. The date the application is signed, or
2. The date of completion of all medical examinations and tests, if required, or
3. The date of issue requested in the application, if any.
A check or draft shall not constitute settlement unless negotiable on the date of this application and honored on the first presentation for
payment.
If one or more of the conditions above is not met, liability of the Company shall be limited to the return of the sum received.
Date Agent
Valid only if signed by an Authorized Company Representative
Notice
(10/17)
Notice
Applicant
MOUNTAIN LIFE INSURANCE COMPANY
2416 Sir Barton Way Suite 110
Lexington, KY 40509
1-800-888-6542
HIPAA COMPLIANT AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Name of Proposed Insured (Please print)
Social Security Number
Birth Date
I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy or pharmacy benefit manager,
insurance company, medical facility, the MIB, Inc., the Veterans Administration, or other health care provider that has provided
payment, treatment or services to me or on my behalf within the past 10 years (“My Providers”) to disclose to Mountain Life
Insurance Company, its reinsurer(s), and insurance supporting organizations and their representatives, my entire medical record,
prescription history, medications prescribed and any other protected health information concerning me. This also includes
information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This
also
includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco, but excludes
psychotherapy notes. I also authorize Mountain Life Insurance Company, or its reinsurers, to make a brief report of my protected
health information to MIB.
By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to
this Authorization, and I instruct any physician, health care professional, hospital, clinic, medical facility or other health care provider
to release and disclose my entire medical record without restriction.
This protected health information is to be disclosed under this Authorization so that Mountain Life Insurance Company may: 1)
underwrite my application for coverage, make eligibility, risk rating, policy issuance and enrollment determinations; 2) obtain
reinsurance; 3) administer claims and determine or fulfill responsibility for coverage and provision of benefits; 4) administer
coverage; and 5) conduct other legally permissible activities that relate to any coverage I have or have applied for with Mountain
Life Insurance Company.
This Authorization shall remain in force for 24 months following the date of my signature below, and a copy of this Authorization is
as valid as the original. I understand that I have the right to revoke this Authorization in writing, at any time, by providing written
notification to Mountain Life Insurance Company. I understand that a revocation is not effective to the extent that any of My
Providers have already replied on this Authorization to disclose information about me or to the extent that Mountain Life
Insurance Company has a legal right to contest a claim under an insurance policy or to contest the policy itself. I understand that
any information that is disclosed pursuant to this Authorization is no longer covered by federal rules governing privacy and
confidentiality of health information, but it will not be redisclosed by Mountain Life Insurance Company except as authorized by me
or as required by law.
I understand that My Providers may not refuse to provide treatment or payment for health care services if I refuse to sign this
Authorization. I further understand that if I refuse to sign this Authorization to release my complete medical record, Mountain Life
Insurance Company may not be able to process my application, or if coverage has been issued, may not be able to make any
benefit payments. I understand that any authorized representative or I will receive a copy of this Authorization upon request.
I authorize my employer, any consumer reporting agency, the Department of Motor Vehicles, other organizations, institutions or
persons having any records or knowledge of me or my health to release any financial or personal data to Mountain Life
Insurance Company or its reinsurers. This information may be used by underwriters, Company Officers, medical and claims
personnel in evaluating applications and claims. They may also use it to consider Life and/or Disability insurance and/or benefits
applied for by me. I understand this authorization is valid for 24 months from the date it is signed. A copy of it is also valid. I
acknowledge having received a copy. I understand that I have the right to revoke this at any time. I also received a copy of NOTICE
OF INSURANCE INFORMATION PRACTICES. I acknowledge receipt of the Conditional Receipt, if applicable, for Life and/or Disability
insurance bearing the same date as this application and certify that I have read it, and its terms, conditions and limitations to which I
agree.
Signature of Proposed Insured or Personal Representative
Date (MM/DD/YYYY)
(09/17)
Notice
Company
MOUNTAIN LIFE INSURANCE COMPANY
2416 Sir Barton Way Suite 110
Lexington, KY 40509
1-800-888-6542
HIPAA COMPLIANT AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Name of Proposed Insured (Please print)
Social Security Number
Birth Date
I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy or pharmacy benefit manager,
insurance company, medical facility, the MIB, Inc., the Veterans Administration, or other health care provider that has provided
payment, treatment or services to me or on my behalf within the past 10 years (“My Providers”) to disclose to Mountain Life
Insurance Company, its reinsurer(s), and insurance supporting organizations and their representatives, my entire medical record,
prescription history, medications prescribed and any other protected health information concerning me. This also includes
information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This
also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco, but excludes
psychotherapy notes. I also authorize Mountain Life Insurance Company, or its reinsurers, to make a brief report of my protected
health information to MIB.
By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to
this Authorization, and I instruct any physician, health care professional, hospital, clinic, medical facility or other health care provider
to release and disclose my entire medical record without restriction.
This protected health information is to be disclosed under this Authorization so that Mountain Life Insurance Company may: 1)
underwrite my application for coverage, make eligibility, risk rating, policy issuance and enrollment determinations; 2) obtain
reinsurance; 3) administer claims and determine or fulfill responsibility for coverage and provision of benefits; 4) administer
coverage; and 5) conduct other legally permissible activities that relate to any coverage I have or have applied for with Mountain
Life Insurance Company.
This Authorization shall remain in force for 24 months following the date of my signature below, and a copy of this Authorization is
as valid as the original. I understand that I have the right to revoke this Authorization in writing, at any time, by providing written
notification to Mountain Life Insurance Company. I understand that a revocation is not effective to the extent that any of My
Providers have already replied on this Authorization to disclose information about me or to the extent that Mountain Life
Insurance Company has a legal right to contest a claim under an insurance policy or to contest the policy itself. I understand that
any information that is disclosed pursuant to this Authorization is no longer covered by federal rules governing privacy and
confidentiality of health information, but it will not be redisclosed by Mountain Life Insurance Company except as authorized by me
or as required by law.
I understand that My Providers may not refuse to provide treatment or payment for health care services if I refuse to sign this
Authorization. I further understand that if I refuse to sign this Authorization to release my complete medical record, Mountain Life
Insurance Company may not be able to process my application, or if coverage has been issued, may not be able to make any
benefit payments. I understand that any authorized representative or I will receive a copy of this Authorization upon request.
I authorize my employer, any consumer reporting agency, the Department of Motor Vehicles, other organizations, institutions or
persons having any records or knowledge of me or my health to release any financial or personal datato Mountain Life
Insurance Company or its reinsurers. This information may be used by underwriters, Company Officers, medical and claims
personnel in evaluating applications and claims. They may also use it to consider Life and/or Disability insurance and/or benefits
applied for by me. I understand this authorization is valid for 24 months from the date it is signed. A copy of it is also valid. I
ackn
owledge having received a copy. I understand that I have the right to revoke this at any time. I also received a copy of NOTICE
OF INSURANCE INFORMATION PRACTICES. I acknowledge receipt of the Conditional Receipt, if applicable, for Life and/or Disability
insurance bearing the same date as this application and certify that I have read it, and its terms, conditions and limitations to which I
agree.
Signature of Proposed Insured or Personal Representative
Date (MM/DD/YYYY)
(09/17)
Notice (09/17)
Mountain Life Insurance Company
2416 Sir Barton Way Suite 110 , Lexington, KY 40509
NOTICE AND CONSENT FOR TESTING OF BODY FLUIDS (BLOOD, URINE, ORAL SPECIMENS) INCLUDING
AIDS-RELATED TESTING
Purpose of this Form
To evaluate your insurability, the insurer named above has requested that you provide a sample of your body fluids for
testing and analysis to determine the presence of human immunodeficiency virus (HIV) antibodies. Other tests may be
performed including determinations of blood cholesterol and related lipids (fats), cotinine, cocaine, and screening for
liver or kidney disorders, diabetes, immune disorders, and other physical conditions. In order to adequately perform all
testing procedures, it may be necessary for you to provide additional samples of several body fluids. The insurer will
contact you if further follow-up testing is needed. By signing and dating this form, you agree that testing may be done
and that underwriting decisions will be based on the test results. The HIV antibody test is a series of tests performed by
a licensed laboratory through a medically accepted procedure.
Pretesting Considerations
Many public health organizations have recommended that before taking an AIDS-related blood test, a person seek
counseling to become informed concerning the implications of such a test. You may wish to consider counseling, at your
expense, prior to being tested.
Meaning of Positive Test Result
The test is not a test for AIDS. It is a test for antibodies to the HIV virus, the causative agent for AIDS, and shows whether
you have been exposed to the virus. A positive test result does not mean that you have AIDS, but that you are at
significantly increased risk of developing problems with your immune system. The test for HIV antibodies is very
sensitive. Errors are rare, but they do occur. Your private physician, a public health clinic, or an AIDS information
organization in your city might provide you with further information on the medical implications of a positive test.
Positive HIV antibody test results will adversely affect your application for insurance.
Confidentiality of Test Results
All test results will be treated confidentially. They will be reported by the laboratory to the insurer. The test results may
be disclosed as required by law or may be disclosed to employees of the insurer who have the responsibility to make
underwriting decisions on behalf of the insurer or to outside legal counsel who needs such information to effectively
represent the insurer in regard to your application. The results may be disclosed to a reinsurer, if the reinsurer is
involved in the underwriting process, or to an insurance affiliate. If an oral specimen is tested for HIV antibodies, the
insurer may request a sample of your blood for further testing. If the insurer is a member of the Medical Information
Bureau (MIB, Inc.) and you choose to decline that request, the insurer will report to the MIB, Inc. a generic code which
specifies only that a blood test has been ordered and not received. Regardless of the number of tests requested, if the
final test results for HIV antibodies/antigens are other than normal, the insurer will report to the MIB, Inc. a generic
code which signifies only a non-specific blood test abnormality, if your HIV antibody/antigen test is normal, no report
will be made about it to the MIB, Inc. Other test results may be reported to the MIB, Inc. in a more specific manner.
Notice (09/17)
Notification of Test Results
A positive HIV antibody test result will be disclosed to a physician you designate. If you do not designate a physician, a
final positive HIV test result will be disclosed to the Cabinet for Human Resources. Because a trained person should
deliver that information so that you can understand clearly what the test result means, please list your private physician
so that the insurer can have your private physician tell you the test result and explain its meaning.
Name of physician for reporting positive test results: ______________________________________________________
Address: _____________________________________________________________________________________
__________________________________________________________________________________________
Consent
I have read and understand this Notice and Consent for Testing of Body Fluids (Blood, Urine, Oral Specimen) including
Aids-Related Testing. I voluntarily consent to the withdrawal of body fluids from me, the testing of body fluids, and the
disclosure of the test results as described above. I understand that I have the right to request and receive a copy of this
authorization. A photocopy of this form will be as valid as the original.
__________________________________________________________________ ____________________
Name of Proposed Insured (Please Print) Birth Date
__________________________________________________________________________________________________
Address (Please Print)
________________________________________________________ _______________ __________________
Signature of Proposed Insured or Parent/Guardian Date Signed State of Residence
Electronic Funds Transfer Authorization for
Mountain Life Insurance Company
I authorize Mountain Life Insurance Company to initiate a monthly electronic funds transfer (EFT)
withdrawal from my designated bank account to satisfy the amount of my monthly premium. I authorize
my financial institution to accept any withdrawals initiated by Mountain Life Insurance Company.
This authority is to remain in full force and effect until Mountain Life Insurance Company has received
written notification from me of its termination in such manner as to afford a reasonable opportunity to act
upon it. A new authorization form must be completed if I close the bank account identified below, or if I
wish to designate a different bank account. I understand that this authorization does not modify or
change any policy provisions.
Check here to authorize Mountain Life Insurance Company
to draft my account for the
initial premium payment and subsequent premium payments subject to the terms of the
life insurance contract.
Signature Date
**PLEASE ATTACH A VOIDED CHECK TO THIS FORM AND SUBMIT WITH APPLICATION**
ML 105 Rev. (5/21)
Name:
Policy Number (if known):
Policyholder Information
Name of Financial Institution:
Address:
City: State: Zip:
Routing Number:
Account Number:
Financial Institution Information
EFT Type:
Checking Account
Savings Account
Monthly Quarterly
Annually
Frequency:
Withdrawal Day (1-28): ___________________________________________________________
Semi-annually
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Completed 26 August 2021

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