Fillable Oxford Life Final Expense Sample Application (Duford Insurance Group)

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Oxford Life Final Expense Sample Application (Duford Insurance Group)

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69831268
ICC17-FE700 APP Page 1 of 6 (c) OLIC 9/2017
TELEPHONE INTERVIEW 1-888-801-5123
SECTION A - PROPOSED INSURED INFORMATION
NAME (FIRST, MIDDLE INITIAL, LAST)
SOCIAL SECURITY NUMBER DATE OF BIRTH GENDER
MALE FEMALE
PLACE OF BIRTH (CITY, STATE)
MAILING ADDRESS
EMAIL ADDRESS
CITY
STATE ZIP
TELEPHONE NUMBER
STREET ADDRESS (REQUIRED IF MAILING ADDRESS IS PO BOX)
CITY STATE ZIP
ARE YOU A U.S. CITIZEN? YES NO
IF NO, ARE YOU A LEGAL PERMANENT U.S. RESIDENT? YES NO IF NO, COVERAGE IS NOT AVAILABLE.
IF YES, PROVIDE THE ALIEN REGISTRATION/USCIS NUMBER AS SHOWN ON YOUR PERMANENT RESIDENT CARD: _______________________________
SECONDARY ADDRESSEE –
We will send a copy of any notice of late payment or policy lapse to this person.
NAME & ADDRESS
: __________________________________________________________________________________________________________
SECTION B – PROPOSED OWNER (Complete only if the proposed owner is not the proposed insured)
NAME (FIRST, MIDDLE INITIAL, LAST)
SOCIAL SECURITY OR TAX ID
NUMBER
DATE OF BIRTH MALE
FEMALE
RELATIONSHIP TO PROPOSED INSURED
STREET ADDRESS
EMAIL ADDRESS
CITY
STATE ZIP
TELEPHONE NUMBER
SECTION C - INSURANCE APPLIED FOR AND PREMIUM PAYMENT MODE
Amount of Insurance Applied for: $________________ Estimated Premium Amount (for selected payment mode): $___________
REQUESTED POLICY DATE:
_________________________
(
IF LEFT BLANK, THE POLICY DATE WILL BE THE DATE THE POLICY IS ISSUED
)
Payment Mode (select one): Monthly Electronic Funds Transfer (EFT) Quarterly Semi-annually Annually
PAYOR NAME (IF PAYOR IS NOT PROPOSED OWNER)
RELATIONSHIP TO PROPOSED INSURED
BILLING ADDRESS (IF BLANK BILLING ADDRESS WILL BE SAME AS POLICY OWNER’S ADDRESS)
Check here if Owner does NOT want the automatic premium loan provision included in the policy:
MAIL POLICY TO: Owner Producer
Application for Individual Whole Life Insurance
Oxford Life Insurance Company
2721 North Central Avenue, Phoenix, Arizona 85004
ASSURANCE
Oxford Life InstaWrite 833-705-4019
69831268
ICC17-FE700 APP Page 2 of 6 (c) OLIC 9/2017
SECTION D - BENEFICIARIES
Percentages for each beneficiary class (primary and contingent) must total 100%. Multiple beneficiaries of the same class will
share the death benefit equally unless percentages are listed.
Name
Address
Date of Birth
Social Security/Tax ID Number
Relationship
Percent
Name
Address
Date of Birth
Social Security/Tax ID Number
Relationship
Percent
Name
Address
Date of Birth
Social Security/Tax ID Number
Relationship
Percent
Name
Address
Date of Birth
Social Security/Tax ID Number
Relationship
Percent
Name
Address
Date of Birth
Social Security/Tax ID Number
Relationship
Percent
Name
Address
Date of Birth
Social Security/Tax ID Number
Relationship
Percent
Name
Address
Date of Birth
Social Security/Tax ID Number
Relationship
Percent
SECTION E - EXISTING COVERAGE AND REPLACEMENT
Does the Proposed Insured or the Proposed Owner have any existing life insurance or annuity policies?
Yes No
Will the purchase of the life insurance policy applied for in this application result in the replacement, termination or change
in value of any existing life insurance or annuity policy?
Yes No
SECTION F – STRANGER OWNED LIFE INSURANCE
NOTICE: State insurance law may prohibit the owner of a life insurance policy from entering into any agreement to sell,
transfer or assign a life insurance policy prior to the date the policy was issued, or within a period of time specified by state
law after the date the policy was issued. You should consult with legal advisors if you have any questions about these
matters.
HAS THE OWNER, PROPOSED INSURED OR ANY BENEFICIARY ENTERED INTO OR MADE PLANS TO ENTER
INTO ANY AGREEMENT TO SELL OR ASSIGN THE OWNERSHIP OF, OR A BENEFICIAL INTEREST IN, THE
APPLIED FOR POLICY?
YES NO IF YES, PLEASE PROVIDE DETAILS: ______________________________________________
Name
Address
Date of Birth
Social Security/Tax ID Number
Relationship
Percent
69831268
ICC17-FE700 APP Page 3 of 6 (c) OLIC 9/2017
SECTION G – MEDICAL QUESTIONS
Part 1 - If any question in this Part 1 of Section G is answered yes, or if the proposed insured’s height and weight are
not within the allowable range, this application will be declined.
1. What is the proposed insured’s height and weight?
H ____ W ____
2. Have you had, or been advised to have by a member of the medical profession, an organ
transplant, or have you been diagnosed by a member of the medical profession as having a
terminal illness (an illness that would reasonably be expected to cause death within 12 months),
or have you been diagnosed, treated (including dialysis) or taken medication for chronic kidney
disease or kidney (renal) insufficiency or kidney or liver failure, or do you have paralysis of
two or more extremities?
YES NO
3. Have you been treated or diagnosed by a member of the medical profession as having Acquired
Immune Deficiency Syndrome (AIDS), AIDS related complex (ARC), or any immune
deficiency related order, or tested positive for the Human Immunodeficiency Virus (HIV)?
YES NO
4. Are you currently: hospitalized, confined to a bed or nursing facility, using oxygen equipment
to assist in breathing, or receiving Hospice Care?
YES NO
5. Have you been diagnosed by a member of the medical profession with diabetes prior to age 30
or have you ever been treated by a member of the medical profession for: insulin shock,
diabetic coma, retinopathy, or diabetic neuropathy?
YES NO
6. Have you ever been diagnosed by a member of the medical profession, treated or taken
medication for: Congestive Heart Failure (CHF) or heart failure, cardiomyopathy, Alzheimer’s
disease, dementia, schizophrenia, bipolar disorder, organic brain syndrome (acute or chronic
mental dysfunction or mental incapacity), Lou Gehrig’s disease (ALS), or Huntington’s
disease?
YES NO
7. Within the past 24 months, have you been confined more than twice to a hospital, nursing
facility, convalescent care facility, assisted living facility, mental facility or Hospice Care?
YES NO
8. Within the past 24 months have you been diagnosed or treated by a member of the medical
profession for: Internal cancer or melanoma, leukemia, lymphoma, stroke, transient ischemic
attack (TIA), or have you had an amputation caused by any disease?
YES NO
9. Have you been diagnosed or treated by a member of the medical profession for more than one
occurrence or any metastasis of any cancer in your lifetime (excluding basal or squamous cell
skin cancer), or are you currently being treated by a member of the medical profession for
cancer or recurrence of cancer?
YES NO
10. Within the past 24 months have you:
a. been medically diagnosed or treated by a member of the medical profession or taken
medication for angina, chronic hepatitis, cystic fibrosis, Pulmonary Fibrosis, chronic
obstructive pulmonary disease (COPD), chronic bronchitis, emphysema, respiratory failure or
required oxygen equipment to assist in breathing?
YES NO
b. been medically diagnosed as having or been treated by a member of the medical profession or
hospitalized for heart attack, heart disease, heart or circulatory surgery (including pacemaker,
by-pass, heart valve replacement, angioplasty or stent implant), uncontrolled high blood
pressure or any procedure to improve circulation to the heart or brain?
YES NO
c. been medically diagnosed or treated by a member of the medical profession for: Hodgkin’s
disease, cirrhosis, liver disease, systemic lupus (SLE), any neuromuscular disease, cerebral
palsy, multiple sclerosis or Parkinson’s disease?
YES NO
11. Within the past 10 years, have you been convicted of a felony or are you currently on parole or
on probation?
YES NO
12. Within the last 5 years have you been treated for, been advised by a medical professional to
have treatment for, or excessively used, alcohol or any drugs of abuse, or have you been
convicted of operating a vehicle while impaired or under the influence of alcohol or any drugs,
or had your driver’s license suspended or revoked, or attempted suicide?
YES NO
13. Have you been declined or postponed for life or health insurance in the past two years?
YES NO
14. Do you have any impairment, whether physical or mental, for which you need or receive
assistance or supervision in performing normal activities of daily living such as dressing,
eating, bathing, incontinence, toileting, taking medications, or moving without any type of
physical assistance?
YES NO
14. Do you currently require human assistance or supervision with any specified activities such as:
eating, dressing, toileting, bathing, transferring from bed to chair, walking, or maintaining
continence?
69831268
ICC17-FE700 APP Page 4 of 6 (c) OLIC 9/2017
Part 2 - If any question in this Part 2 of Section G is answered yes, it may not necessarily cause this application to be
declined.
15. Are you taking or have you been prescribed medication by a member of the medical profession
for any impairment in Section G?
YES NO
16. Within the past 12 months, have you used any nicotine based products, any form of electronic
cigarette (including nicotine-free electronic cigarettes), or marijuana?
YES NO
17. Have you applied for life insurance with any other insurance companies in the last two years?
YES NO
18. Proposed insured’s driver’s license number _______________________ State _____ None
REPRESENTATIONS, AUTHORIZATIONS AND SIGNATURE
MEDICAL AND CONSUMER REPORTS AUTHORIZATION (this authorization complies with the HIPAA Privacy
Rule): For underwriting and claims purposes, I authorize any physician, medical practitioner, hospital, medical care facility,
pharmacy, pharmacy benefit manager, the Veteran’s Administration or other health care provider, and any insurance
company, insurance support organization (such as MIB, Inc. (“MIB”)), insurance laboratories, my employer, consumer
reporting agency or state department of motor vehicles, to disclose information about me, including but not limited to, my
entire medical record, or any other protected health or consumer information, to Oxford Life Insurance Company (“Oxford
Life”), its reinsurers and those who perform services for Oxford Life related to an insurance application or a claim. This
includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection, sexually transmitted
diseases and mental illness, and the use of alcohol and drugs. I agree that a copy of this authorization or my recorded voice
or electronic authorization is as valid as the original and I can obtain a copy on request. This authorization is valid for 36
months (or a shorter time period if required by applicable state law) from the date of this application (180 days for HIV-
related information), regardless of my condition and whether living or deceased. I can revoke this authorization at any time
by written notice to Oxford Life (Attention: Policyholder Services Department,
2721 N. Central Ave., Phoenix, AZ 85004).
Revocation will not be effective to the extent that this authorization has been relied upon or to the extent that Oxford Life has
a legal right to contest a claim under an insurance policy or to contest the policy itself. Information disclosed pursuant to this
authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations
(such as the HIPAA Privacy Rule). However, Oxford Life will protect the privacy of health information in accordance with
applicable state and federal privacy laws and its own privacy policies. I authorize Oxford Life, or its reinsurers, to make a
brief report of my protected health information to MIB. I acknowledge receipt of the MIB Pre-Notice, the Fair Credit
Reporting Act Notice and the Privacy Notice. I understand that my health care providers may not condition providing
treatment or payment for health care services on my signing of this authorization. I further understand that if I refuse to sign
this authorization Oxford Life will not be able to process my application.
_____________________________________________________
Date: ___________________________
Signature of Primary Proposed Insured/Personal Representative
If signed by an individual’s Personal Representative, please describe authority to sign on behalf of the individual:
Power of Attorney Other (please describe): __________________________________________________
REPRESENTATIONS AND ACKNOWLEDGEMENTS:
I have read and understand this application. I am not currently taking and I am not under the influence of any medications or
drugs that would affect my ability to fully understand and fully complete this application. Under penalties of perjury, I
certify that I am a U.S. citizen (including a U.S. resident alien) and that my correct taxpayer identification number is shown
on this form. All statements and answers in this application are true and complete to the best of my knowledge and belief,
are the basis for any policy issued, and will be made a part of the policy. No information about me will be considered to
have been given to Oxford Life by me unless it is stated in this application or during the application process.
The producer does not have authority to: accept risk, pass on insurability, waive, make void, change, or modify any
provisions, questions or answers given in this application, approve this application, change the policy, or advise me that any
inaccurate application response is acceptable.
69831268
ICC17-FE700 APP Page 5 of 6 (c) OLIC 9/2017
NO IMMEDIATE LIFE INSURANCE COVERAGE.
Oxford Life will have no liability under this application unless, and until: a) the application has been received and approved
by Oxford Life at its Home Office; b) the policy has been issued and delivered to the owner during the lifetime of the
Proposed Insured; c) the first premium has been paid to and accepted by Oxford Life and honored by the issuing financial
institution on the policy applied for; and d) at the time of delivery and payment, the facts concerning the insurability of the
Insured remain as stated during the application process.
WARNING: Any person who knowingly presents a false statement in an application for insurance may be guilty of a
criminal offense and subject to penalties under state law.
REVIEW THE ANSWERS ON THIS APPLICATION CAREFULLY. OXFORD LIFE WILL RELY ON THIS
APPLICATION TO DETERMINE INSURABILITY. IF ANY OF YOUR ANSWERS ARE INCORRECT OR
UNTRUE, THE COMPANY MAY HAVE THE RIGHT TO DENY BENEFITS BY RESCINDING YOUR POLICY.
RESCINDING YOUR POLICY WILL HAVE AN ADVERSE IMPACT ON YOUR INTENDED BENEFICIARY.
Signed at (City, State): __________________________________ Date:
________________________
___________________________________________
___________________________________________
Signature of Proposed Insured
Signature of Proposed Owner
PRODUCER’S REPORT AND SIGNATURE
Do you have reason to believe that the Proposed Insured or the Proposed Owner has any existing life insurance or annuity
policies? If yes, a replacement form is always required in states that have adopted the NAIC model replacement
regulation, even if the policy applied for in this application will not actually replace any existing coverage.
Yes No
Do you have reason to believe that the insurance applied for in this application will result in the replacement, termination or
change in value of any existing life insurance or annuity policy? If yes, all requested information about any replaced policy
must be provided on the replacement form.
Yes No
I certify the following to Oxford Life: I personally solicited this application and all information recorded on this
application is true to the best of my knowledge. The Proposed Insured and Owner seemed to me to be lucid and fully
understand all of the questions on this application. If this transaction involves a replacement, I gathered all relevant
information regarding the replaced product and determined that the replacement is suitable and in compliance with the
Company’s position on replacements. To my knowledge, the policy applied for will not be sold or assigned for any type of
senior settlement, life settlement or any other secondary market.
Producer’s Signature_________________________________________ Date ________________
Producer’s Printed Name _____________________________________ Producer’s Number _______________
PRIVACY NOTICE
Your privacy is protected. Oxford Life Insurance Company (We, Us, Our), like other insurance companies, sometimes
evaluates the medical history and other personal information about applicants to determine their eligibility for certain
policies. (Personal information includes information such as age, occupation, physical condition, health history, habits,
general reputation, credit and career.) We also use this information to administer your insurance coverage after it is in force.
Any information you give Us regarding your insurability and any information received from other sources will be treated as
strictly confidential. In some situations, and in compliance with applicable law, We may disclose information to third parties
without further authorization. We may also disclose this information to: (1) an organization performing administrative,
business or professional services for Us; (2) other insurance companies to which you apply; or (3) your physician or medical
professional.
ICC17-FE700 APP Page 5 of 6 (c) OLIC 9/2017
NO IMMEDIATE LIFE INSURANCE COVERAGE.
Oxford Life will have no liability under this application unless, and until: a) the application has been received and approved
by Oxford Life at its Home Office; b) the policy has been issued and delivered to the owner during the lifetime of the
Proposed Insured; c) the first premium has been paid to and accepted by Oxford Life and honored by the issuing financial
institution on the policy applied for; and d) at the time of delivery and payment, the facts concerning the insurability of the
Insured remain as stated during the application process.
WARNING: Any person who knowingly presents a false statement in an application for insurance may be guilty of a
criminal offense and subject to penalties under state law.
REVIEW THE ANSWERS ON THIS APPLICATION CAREFULLY. OXFORD LIFE WILL RELY ON THIS
APPLICATION TO DETERMINE INSURABILITY. IF ANY OF YOUR ANSWERS ARE INCORRECT OR
UNTRUE, THE COMPANY MAY HAVE THE RIGHT TO DENY BENEFITS BY RESCINDING YOUR POLICY.
RESCINDING YOUR POLICY WILL HAVE AN ADVERSE IMPACT ON YOUR INTENDED BENEFICIARY.
Signed at (City, State): __________________________________ Date:
________________________
___________________________________________
___________________________________________
Signature of Proposed Insured
Signature of Proposed Owner
PRODUCER’S REPORT AND SIGNATURE
Do you have reason to believe that the Proposed Insured or the Proposed Owner has any existing life insurance or annuity
policies? If yes, a replacement form is always required in states that have adopted the NAIC model replacement
regulation, even if the policy applied for in this application will not actually replace any existing coverage.
Yes No
Do you have reason to believe that the insurance applied for in this application will result in the replacement, termination or
change in value of any existing life insurance or annuity policy? If yes, all requested information about any replaced policy
must be provided on the replacement form.
Yes No
I certify the following to Oxford Life: I personally solicited this application and all information recorded on this
application is true to the best of my knowledge. The Proposed Insured and Owner seemed to me to be lucid and fully
understand all of the questions on this application. If this transaction involves a replacement, I gathered all relevant
information regarding the replaced product and determined that the replacement is suitable and in compliance with the
Company’s position on replacements. To my knowledge, the policy applied for will not be sold or assigned for any type of
senior settlement, life settlement or any other secondary market.
Producer’s Signature_________________________________________ Date ________________
Producer’s Printed Name _____________________________________ Producer’s Number _______________
PRIVACY NOTICE
Your privacy is protected. Oxford Life Insurance Company (We, Us, Our), like other insurance companies, sometimes
evaluates the medical history and other personal information about applicants to determine their eligibility for certain
policies. (Personal information includes information such as age, occupation, physical condition, health history, habits,
general reputation, credit and career.) We also use this information to administer your insurance coverage after it is in force.
Any information you give Us regarding your insurability and any information received from other sources will be treated as
strictly confidential. In some situations, and in compliance with applicable law, We may disclose information to third parties
without further authorization. We may also disclose this information to: (1) an organization performing administrative,
business or professional services for Us; (2) other insurance companies to which you apply; or (3) your physician or medical
professional.
69831268
ICC17-FE700 APP Page 6 of 6 (c) OLIC 9/2017
You can make a written request to review personal information about you in Our files. You also may request correction of
information you believe to be inaccurate.
THE ABOVE IS A GENERAL DESCRIPTION OF OUR PRIVACY PRACTICES. FOR A MORE DETAILED
EXPLANATION OF OUR PRIVACY PRACTICES, PLEASE WRITE TO OUR PRIVACY OFFICER AT OXFORD LIFE
INSURANCE COMPANY,
2721 NORTH CENTRAL AVENUE, PHOENIX, AZ 85004-1172, OR VISIT
WWW.OXFORDLIFE.COM.
FAIR CREDIT REPORTING ACT NOTICE
With regard to your application, We may request a consumer report or an investigative consumer report. These reports contain
information about your character, general reputation, mode of living and health. No adverse underwriting decision will be made based on
your sexual orientation. The information may have been obtained through interviews with you, your neighbors, friends and others who
know you. Upon request, We will give you the name and address of the consumer reporting agency so that you may request a copy of the
report.
MIB PRE-NOTICE
Information regarding Your insurability will be treated as confidential. Oxford Life Insurance Company, or its reinsurers, may, however,
make a brief report thereon to MIB, Inc. (“MIB”), 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, the 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. Please contact MIB at 866-
692-6901. If you question the accuracy of information in MIB’s file, you may contact MIB and seek a correction in accordance with the
procedures set forth in the federal Fair Credit Reporting Act. The address of MIB’s information office is: 50 Braintree Hill Park, Suite
400, Braintree, Massachusetts 02184-8734.
Oxford Life Insurance Company, or its reinsurers, may also release information in its file to MIB and to other i
nsurance companies to
whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. Information for consumers about
MIB may be obtained on its website at
www.mib.com.
PREMIUM RECEIPT
I have received a check, or a completed and signed Electronic Funds Transfer (“EFT”) authorization for an electronic draft,
for the initial premium from the proposed policy payor in the amount of $___________________ with the application for
life insurance on the life of ______________________________________________________________.
(Proposed Insured’s Name)
Oxford Life Insurance Company will refund this amount, if collected, if no policy is issued. This is a premium receipt
only. It does not provide conditional, temporary or any other insurance coverage. If a policy is issued, insurance
will be in effect on the Policy Date, provided that the funds for the first premium payment have been paid to and
accepted by Oxford Life and honored by the issuing financial institution while the Proposed Insured is alive.
Producer’s signature Date
ICC17-FE700 APP Page 5 of 6 (c) OLIC 9/2017
NO IMMEDIATE LIFE INSURANCE COVERAGE.
Oxford Life will have no liability under this application unless, and until: a) the application has been received and approved
by Oxford Life at its Home Office; b) the policy has been issued and delivered to the owner during the lifetime of the
Proposed Insured; c) the first premium has been paid to and accepted by Oxford Life and honored by the issuing financial
institution on the policy applied for; and d) at the time of delivery and payment, the facts concerning the insurability of the
Insured remain as stated during the application process.
WARNING: Any person who knowingly presents a false statement in an application for insurance may be guilty of a
criminal offense and subject to penalties under state law.
REVIEW THE ANSWERS ON THIS APPLICATION CAREFULLY. OXFORD LIFE WILL RELY ON THIS
APPLICATION TO DETERMINE INSURABILITY. IF ANY OF YOUR ANSWERS ARE INCORRECT OR
UNTRUE, THE COMPANY MAY HAVE THE RIGHT TO DENY BENEFITS BY RESCINDING YOUR POLICY.
RESCINDING YOUR POLICY WILL HAVE AN ADVERSE IMPACT ON YOUR INTENDED BENEFICIARY.
Signed at (City, State): __________________________________ Date:
________________________
___________________________________________
___________________________________________
Signature of Proposed Insured
Signature of Proposed Owner
PRODUCER’S REPORT AND SIGNATURE
Do you have reason to believe that the Proposed Insured or the Proposed Owner has any existing life insurance or annuity
policies? If yes, a replacement form is always required in states that have adopted the NAIC model replacement
regulation, even if the policy applied for in this application will not actually replace any existing coverage.
Yes No
Do you have reason to believe that the insurance applied for in this application will result in the replacement, termination or
change in value of any existing life insurance or annuity policy? If yes, all requested information about any replaced policy
must be provided on the replacement form.
Yes No
I certify the following to Oxford Life: I personally solicited this application and all information recorded on this
application is true to the best of my knowledge. The Proposed Insured and Owner seemed to me to be lucid and fully
understand all of the questions on this application. If this transaction involves a replacement, I gathered all relevant
information regarding the replaced product and determined that the replacement is suitable and in compliance with the
Company’s position on replacements. To my knowledge, the policy applied for will not be sold or assigned for any type of
senior settlement, life settlement or any other secondary market.
Producer’s Signature_________________________________________ Date ________________
Producer’s Printed Name _____________________________________ Producer’s Number _______________
PRIVACY NOTICE
Your privacy is protected. Oxford Life Insurance Company (We, Us, Our), like other insurance companies, sometimes
evaluates the medical history and other personal information about applicants to determine their eligibility for certain
policies. (Personal information includes information such as age, occupation, physical condition, health history, habits,
general reputation, credit and career.) We also use this information to administer your insurance coverage after it is in force.
Any information you give Us regarding your insurability and any information received from other sources will be treated as
strictly confidential. In some situations, and in compliance with applicable law, We may disclose information to third parties
without further authorization. We may also disclose this information to: (1) an organization performing administrative,
business or professional services for Us; (2) other insurance companies to which you apply; or (3) your physician or medical
professional.
ICC17-FE700 APP Page 6 of 6 (c) OLIC 9/2017
You can make a written request to review personal information about you in Our files. You also may request correction of
information you believe to be inaccurate.
THE ABOVE IS A GENERAL DESCRIPTION OF OUR PRIVACY PRACTICES. FOR A MORE DETAILED
EXPLANATION OF OUR PRIVACY PRACTICES, PLEASE WRITE TO OUR PRIVACY OFFICER AT OXFORD LIFE
INSURANCE COMPANY,
2721 NORTH CENTRAL AVENUE, PHOENIX, AZ 85004-1172, OR VISIT
WWW.OXFORDLIFE.COM.
FAIR CREDIT REPORTING ACT NOTICE
With regard to your application, We may request a consumer report or an investigative consumer report. These reports contain
information about your character, general reputation, mode of living and health. No adverse underwriting decision will be made based on
your sexual orientation. The information may have been obtained through interviews with you, your neighbors, friends and others who
know you. Upon request, We will give you the name and address of the consumer reporting agency so that you may request a copy of the
report.
MIB PRE-NOTICE
Information regarding Your insurability will be treated as confidential. Oxford Life Insurance Company, or its reinsurers, may, however,
make a brief report thereon to MIB, Inc. (“MIB”), 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, the 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. Please contact MIB at 866-
692-6901. If you question the accuracy of information in MIB’s file, you may contact MIB and seek a correction in accordance with the
procedures set forth in the federal Fair Credit Reporting Act. The address of MIB’s information office is: 50 Braintree Hill Park, Suite
400, Braintree, Massachusetts 02184-8734.
Oxford Life Insurance Company, or its reinsurers, may also release information in its file to MIB and to other i
nsurance companies to
whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. Information for consumers about
MIB may be obtained on its website at
www.mib.com.
PREMIUM RECEIPT
I have received a check, or a completed and signed Electronic Funds Transfer (“EFT”) authorization for an electronic draft,
for the initial premium from the proposed policy payor in the amount of $___________________ with the application for
life insurance on the life of ______________________________________________________________.
(Proposed Insured’s Name)
Oxford Life Insurance Company will refund this amount, if collected, if no policy is issued. This is a premium receipt
only. It does not provide conditional, temporary or any other insurance coverage. If a policy is issued, insurance
will be in effect on the Policy Date, provided that the funds for the first premium payment have been paid to and
accepted by Oxford Life and honored by the issuing financial institution while the Proposed Insured is alive.
Producer’s signature Date
EFT-NBFE-OLIC (rev. 7/19)
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION
POLICY NUMBER:
BANK ACCOUNT TYPE: CHECKING SAVINGS
BANK ACCOUNT OWNER NAME
SAME AS INSURED SAME AS POLICY OWNER or PRINT NAME:
BANK ACCOUNT OWNER ADDRESS
RELATIONSHIP TO INSURED
BANK NAME
ROUTING NUMBER
BANK ACCOUNT NUMBER
USE THIS SECTION ONLY IF YOU WANT TO REQUEST A PAYMENT DATE AND POLICY DATE THAT
COINCIDES WITH YOUR SOCIAL SECURITY PAYMENT DATE.
Please make my policy date and draft date the:
Month __________ Second Wednesday Third Wednesday Fourth Wednesday
Please leave Requested Policy Date Blank in Section C of the Application.
For checking accounts, attach a voided check over this section. For savings accounts, attach a bank account
statement. DO NOT ATTACH A DEPOSIT SLIP. A deposit slip may delay processing.
Refer to this diagram for instructions on where to
locate your bank routing and account numbers.
Oxford Life will draft the first premium at the time the policy is effective or issued, whichever is later. Subsequent drafts
will occur on the same day of the month as the policy’s effective date (or the Social Security payment date if that option is
selected).
I have read, understand and agree to the following:
I authorize Oxford Life Insurance Company to electronically debit all premiums (at the rate for the payment frequency
selected in my application) from the bank account identified above. If the premium for the face amount applied for differs
from the estimated premium quoted on an application submitted with this form, I authorize Oxford Life to debit the actual
premium amount due from my bank account. This authorization may be terminated by me or by Oxford Life. I may
revoke this authorization by written notice to Oxford Life or by calling (866) 641-9999. If this authorization is revoked,
Oxford Life will initiate quarterly paper billings. Oxford Life will NOT consider my premium paid if my bank does not
honor an EFT request. If a bank return is received due to insufficient funds, Oxford Life will attempt a second draft from
your bank account immediately upon notice of the first return. Any bank fees incurred due to bank returns will not be
reimbursed by Oxford Life.
IF THE POLICY OWNER IS NOT THE OWNER OF THE BANK ACCOUNT IDENTIFIED
ABOVE, THEN THE BANK ACCOUNT OWNER MUST ALSO SIGN THIS FORM.
___________________________________________ ___________________________________________
Signature – Policy Owner Date Signature – Bank Account Owner Date
Oxford Life Mailing Address and Contact Information
Regular mail or
overnight
Marketing
New Business
Existing Policies
2721 North
Central Avenue,
Phoenix, AZ
85004
Phone
800-308-2318
Phone
866-641-9999
Phone
866-641-9999
Fax
866-380-9691
Fax
877-584-2777
Fax
877-584-2777
E-Mail
marketing@oxfordlife.com
E-Mail
fastapps@oxfordlife.com
E-Mail
oxfordphs@oxfordlife.com
Your Name
Your Address
-VOID-
Routing Number Account Number
123456789 1234567
ASSURANCE
FINAL EXPENSE LIFE INSURANCE
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Oxford Life Final Expense Sample Application (Duford Insurance Group)

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Completed 7 July 2021

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