Insurance Application Form

INSURED’S INFORMATION

Owner (If other than insured)

Primary Care Physician

Complete only if applying for First-Day coverage.

Certificate Information
Face Amount $

Total Paid to Agent $
Face Amount $

Total Paid to Agent $
Face Amount $

Total Paid to Agent $
Premium Amt $
Premium Amt $

Beneficiaries

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materiallly false information or conceals for the purpose of lisleading, information concerning any fact material thereto comits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

ASSIGNMENT
Yes No
Initial Approval
 I hereby irrevocably assign and transfer all the benefits and proceeds of this certificate to as their interest may appear. I understand fully the effects of this assignment and transfer. It is my intention as owner to continue to pay premiums and retain ownership.

MULTI-PAY HEALTH QUESTIONS
Yes No
Initial
 1. Now or within the last two years, has the insured been, or been told to be and refused to be, hospitalized or in a nursing facility?
Yes No
Initial
 2. In the last two yers, has the insured been diagnosed, treated, or prescribed drugs by a healthcare provider of any of the following diseases? Cancer. Tumor, Insulin-Dependent Diabetes, Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS), or Acquried Immune Deficiency Syndrome-RelatedComplex (ARC), any Disorder of the Blood, Kidney, Lung, Brain, Heart, Circulatory System or Liver?

I affirm that both the above health questions have been answered correctly. If either of the health questions is answered "yes," or is not answered, I will be issued a certificate with a two-year limited death benefit, per thousand dollars of face amount as out-lined below:

Plan Type 1st-Yr Monthly Increases 12th Month Value 2nd-Yr Monthly Increases 24th Month Value 25th Month Value and thereafter Initials
1-Yr $94 $1,000 - $1,000 $1,000
3-yr $41 500 $41 $1,000 $1,000
5-yr $41 400 $41 $9000 $1,000
10-yr $25 300 $33 700 $1,000

AGREEMENT

By signing below, I agree that: (1) To the best of my knowledge and belief, statements in this Application are complete and true. (2) When the certificate is delivered, the Insured must be alive and in the same health as described above or there will be no insurance. Also, the full premium for the chosen period must be paid by the time the certificate is delivered. (3) By accepting the certificate, I approve any change(s), correction(s), or addition(s) that Great Western made when issuing it. If my approval requires written consent, a form will be included.

Insurable Interest: If the owner is other than the insured, by signing below, the owner certifies that he/she has insurable interest in the life of the insured as defined by the state statute in which the policy is issued.

Authorization: By signing below, I approve of any healthcare provider, medical facility, or other person, including a Veterans Administration Hospital, giving the Great Western Insurance Company any records or information it needs about the Insured’s health. A copy of this approval will be as effective as the original. This approval is only valid for 30 months. The Insured, or a person authorized to act on behalf of the Insured, is entitled to receive a copy of this authorization upon request. I affirm that no illustration was used in the sale of this product.

Signed at ,   Insured
Parent or Guardian, If Juvenile Insured
Owner
If Other Than Insured 		Agent #
Replacement of insurance is involved. Yes No

To the Applicant: You should hear from the Company within sixty days of the application date. If you don’t, state the facts of your application in a letter to the Secretary of Great Western Insurance Company at the address listed above.

AUTHORIZATION AGREEMENT FOR PREAUTHORIZED AUTOMATIC BANK WITHDRAWALS

Please Attach a Voided Check

(The first nine numbers
on the bottom of the check)

I hereby authorize Great Western Insurance Company (THE COMPANY) to initiate debit entries. If necessary, THE COMPANY may credit entries on the above named financial institution and account.

This authorization is to remain in full force and effect until THE COMPANY receives written notice of its termination. The notice must be in such time and in such manner as to allow THE COMPANY and DEPOSITORY reasonable time to act (minimum of three weeks).