William Penn Life, 1994 (29. évfolyam, 1-12. szám)

1994-04-01 / 4. szám

1 1

April 1994, William Penn Life, Page 7

Application for Single Premium Whole Life and $20,000.00 Juvenile Term to Age 25 Insurance Plans

WILLIAM PENN ASSOCIATION

A FRATERNAL BENEFIT SOCIETY • SINCE 1886 SECTION A Pittsburgh, Pennsylvania 15233

1. Proposed First Name Middle Last □ M Insured: □ F

14. a. Plan: (describe fully)

2. Residence Street City State Zip Address:

b. Face Amount: ; or

amount purchased by (mode) premium nf $

3. Date of 4. Place of Birth 5. Marital Birth: (Mo-Day-Yr) State or Country: Status:

c. Include Rider Benefits:

□ ADB, Amount DWP

□ GPO, Amount □ Payor

□ Family Bene., Units DRPO

□ FPA, form no. □

Auto. Prem. Pymt. □ Yes □ No

□ Deer. Term, form no. □

Yrs___Initial Amount

6. Occupation:

7. How long at present occupation:

8. Beneficiary: (Show name and relationship to Proposed Insured) Primary:

Contingent:

9. Do you intend to fly; or, have you flown within the past 2 years as a pilot, or crew member? Yes □ No □ If “yes” will you accept an exclusion rider? Yes □ No □ If not, complete an aviation questionnaire.

15. (a) Premiums to be paid:

□ Ann. □ Semi-Ann. □ Qtrly 0 Monthly

(b) Automatic Prem. Loan: QYes □ No

(c) Amount paid with App.: $

10. Is this insurance being purchased to replace or change any existing insurance or any annuity? Yes □ No □ If "yes" what company and policy number?

16. Requested Certificate Date (If none shown, Requested Date will be the later date of this application or any required medical examination.) Certificate years and anniversaries will be computed from the Certificate Date.

/ /

11. Have you ever been treated or counseled for: alcoholism; or, used marijuana, LSD, or heroin? Yes □ No □ If "yes" give details on separate memo.

12. Insurance now in force: Life ADB

13. Home Office Use Only

month day year

SECTION B. Additional Information Regarding the Proposed Insured.

1. HEIGHT:___Ft------In. 2. WEIGHT:____Lbs. 3. Give weight gained or lost in past year:____Reason.

4. Have you had or been told you had: Yes No

a. Asthma; emphysema; or, other lung or respiratory

disease or disorder?......................................... □ □

5. Have you, within the last five years, had an: Yes No electrocardiogram; X-ray; blood study or, other special diagnostic test?................................................... □ □

b. Any disease or disorder of the brain or nervous system? ............................................................ □ □

c. Kidney disease; diabetes; or, other disease or disorder

of the genitourinary system?.............................. □ □

d. High blood pressure; chest pain; rheumatic fever; heart

disease; or, other circulatory disease or disorder?.. . □ □

e. Ulcer; disease or disorder of the stomach, liver or intestines?........................................................ □ □

f. Tumor or any malignancy?................................. □ □

g. Deformity; lamness; or, any physical or mental impairment? ......................................................... □ □

h. Any surgical operations;................................... □ □

i. Any other injury, disease or disorder in the past five

years?......................................................... □ □

6. Have you been under: observation, care or treatment in

any: hospital; sanitarium; or, othei institution?......... □ □

7. Have your applications for life or health insurance ever

been: declined; postponed; or, modified?................. □ □

8. Do you have other applications for life or health insurance

now pending?..................................................... □ □

9. a. Have you had any disease or disorder of the breast or

reproductive organs?........................................ □ □

b. Are you pregnant? (How far advanced?)

10. Name and address of personal doctor

Date and reason last consulted

11. Give details regarding any “yes" for Questions 4 through 9. (please print)

Question Illness Name & Addresses of Degree of

Number Injury Date Doctors & Hospitals Recovery

12. Dividend Election:

□ Cash DReduce Premiums □ Paid-Up Ins.

□ Accumulate

□ One Year Term Addition

13. Is the Proposed Insured a member of the William Penn Association?□Yes DNo

If not, apply for membership.

Having read the above statements and answers, I represent that, to the best of my knowledge and belief, the answers to the statements are true and complete. I agree that: (1) this application and any supplement or continuation thereof shall be the basis for and a part of any insurance contract issued: (a) on the basis applied for; (b) on a basis other than as applied for; or (c) with an endorsement in the Home Office section above; and (2) except as may be otherwise provided in a Conditional Receipt bearing the same date as this application, no insurance shall take effect until: (a) a certificate is issued and delivered to me; (b) the full first premium thereon is paid; and (c) all while the health and other conditions affecting the insurability of each person on whom insurance is requested remain as described in this application; and (3) unless otherwise stated in this application, the Owner of the insurance contract shall be: (a) the Applicant, if other than the Proposed Insured; or (b) the Proposed Insured.

I understand that: (1) no information acquired by an agent or representat ive of the William Penn Association shall bind the William Penn Association unless set out in writing in this application; (2) no agent or person other than an officer of the William Penn Association is authorized to: (a) make or modify contracts; or (b) waive any of the rights or requirements of the William Penn Association; and (3) in those states where statutes or regulations so require, the following changes will be made in this application only with my written consent: (a) Plan; (b) Amount; (c) Classification of Risk; (d) Age; or (e) Benefits.

Application made at ____________________________

Signatures:

Proposed Insured: _____________________________

Adult Applicant and

Owner or Member Applicant:_______________________

Form No. AC-9-81

* í 1 rt.fl I T-F'-l M r.i'V « • • n 1 r . « > i r •» e <

this

_day of

19

Witness

(licensed agent)

Proposed Insured’sSoc. Sec. No_________

t. • I . I.

IMPORTANT

Applicant MUST sign the Authorization below and submit it with Application.

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