Agent Practitioner
Resume:
Plan Code Benefit Amount, Home Office Use Only
CANLS-AP(04)
CALIFORNIA Application Continued on Back
1. Full Name(s) of Family Member(s) to be insured
2. Where should Premium Notices be sent?
Residence Address
Street or Route:
City:
Applicant's Social Security Number
- -
Name
Applicant / Primary Insured's First Name M.I. Last Name
(a)
State: Zip Code:
Applicant's E-mail Address:
Age
Date of Birth
M M D D Y Y
Spouse / Covered Adult's First Name M.I. Last Name
(b)
(c)
Child / Covered Person's First Name M.I. Last Name Child / Covered Person's First Name M.I. Last Name
(d)
(e)
Child / Covered Person's First Name M.I. Last Name Child / Covered Person's First Name M.I. Last Name
(f)
Age
Age
Age
Age
Age
M M D D Y Y
M M D D Y Y
M M D D Y Y
M M D D Y Y
M M D D Y Y
Sex
M F
A recorded interview may be
necessary as part of the
underwriting of your application for
insurance. The most convenient
time and place for the interview is:
8 AM - Noon
Noon - 6 PM
6 PM - 9 PM
Home Phone No.
Work Phone No.
Application
Verification
Information - -
- - Will the insurance
being applied for
replace or change any
existing insurance?
Yes
No
Mode of Premium Payment
Annual Semi-Annual
Quarterly Monthly (APP only)
Send Premium Notices
Automatic Payment Plan
Day (01-28) of the Month
to Draft Bank Account
APPLICATION FOR INSURANCE - UNITED AMERICAN INSURANCE COMPANY - A LEGAL RESERVE STOCK COMPANY - ADMINISTRATIVE OFFICES: McKINNEY, TEXAS 1220
19764
K21 10 000
Carmen Contreras 03 21 67 55
Carmen Contreras
227 4th Street
Fillmore CA 93015
05
570 29 8753 ***********@*****.***
IF THE ANSWER TO ANY OF THE OTHER QUESTIONS IS "YES," THE PROPOSED INSURED IS NOT ELIGIBLE FOR COVERAGE. FILL IN APPLICABLE BUBBLE FOR ANY PROPOSED INSURED TO WHOM A "YES" ANSWER APPLIES. IF THE ANSWER TO QUESTION 3 IS "YES", THEN CONTINUE. IF THE ANSWER IS "NO" THE INSURED IS NOT ELIGIBLE FOR COVERAGE. I hereby apply to United American Insurance Company for a policy to be issued in reliance upon my written answers to the foregoing questions. The answers are, to the best of my knowledge and belief, true. I agree the policy shall not be effective unless it has actually been issued. I have received an outline of coverage for the policy applied for. I authorize any insurance company, hospital, physician, or other practitioner having any information available as to my diagnosis, treatment, and prognosis, with respect to any physical or mental condition and/or treatment, to disclose such information to United American Insurance Company for the purpose of determining my eligibility for insurance and eligibility for benefits under this policy. I understand that any information obtained will not be released to any person or organization except to reinsuring companies or other persons or organizations performing business or legal services in connection with this application, with a claim, or as may be otherwise lawfully required. I agree that a photostat of this authorization is to be acceptable. This authorization will remain in effect for a period of 24 months from the date signed. I understand that I may request a copy of this authorization. California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage. The undersigned Agent certifies that the Applicant has read, or had read to him, the completed application and that the Applicant realizes that any false statement or misrepresentation in the application may result in a loss of coverage under the policy. CANLS-AP(04) Agent's Signature
Mail Policy to:
Agent
Insured
Agent's Number
Agent's Last Name Amount paid to Agent: $, .
for first months premiums.
City State Applicant's Signature
I understand that no benefits are payable for a diagnosis of cancer in the first 30 days after the effective date of this policy. Application
Signed at,
M M D D Y Y
If so, with which company?
3. Do you have comprehensive medical coverage? 1a 1b 1c 1d 1e 1f YES/NO
Requested Effective Date (mm-dd-yyyy)
- - 2 0
Has this person ever been diagnosed or treated by a physician for internal or skin cancer, melanoma, malignant growth, leukemia, Hodgkin's disease, or premalignant lesions?
4.
App.
Spse.
Child
Child
Child
Child
5. Has this person ever been diagnosed or treated by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS), or AIDS Related Complex (ARC) ?
6. Within the past 2 years, has this person been advised by a physician to have medical tests or examinations to diagnose a possible malignancy but not yet done so?
Yes No
To the best of your knowledge as writing Agent, is the insurance applied for intended to replace any existing insurance?
I certify I have personally seen the Applicant and accurately recorded the information supplied by the Applicant.
I certify I have given an outline of coverage for the policy applied for to the Applicant. 19764
X
Blue Shield
CA
36.00
X
A84055
10 01 22
Steve 01
Fillmore
Contact this candidate