American Home Life Application Disclosures
DECLARATIONS AND AUTHORIZATION DECLARATIONS
I have read and received the Pre-Notices attached to this application. I agree that: 1) all statements and answers are true and complete; 2) this application will be a part of the policy; 3) temporary insurance coverage starts and remains in effect only as provided in the "Conditional Receipt". I certify, under penalty of perjury that the social security numbers shown on the application are correct. I understand that the agent is not authorized to accept risks or pass on insurability, to make or modify contracts, or waive the Company’s rights including the requirement that the adult Proposed Insured personally sign this application in the agent’s presence. If the Company does not issue a policy from this application, the application will be canceled and a refund will be made. By accepting a policy issued from this application, the owner agrees to any changes made by the Company. I understand that I may attend any and all meetings of the policyholders of the Company. If I do not attend, the Executive Committee of the Board of Directors will act as my lawful proxy, until that proxy is revoked by me, in writing. The annual meeting of policyholders shall be held at 10:00 a.m. on the second Tuesday in March, each year. I permit the Company to give information about me and any Proposed Insured except HIV test results to MIB, any reinsurer, and other insurer(s) from which benefits have been claimed or insurance purchased. I acknowledge receipt of the Notice Regarding MIB, Notice Regarding Fair Credit Reporting Act and Notice of Information Practices before signing this form. I understand that I may request in writing to be interviewed. If any investigative consumer report is prepared in connection with this application, upon written request, I am entitled to receive a copy. I understand that there is no benefit paid for suicide for the first two policy years.
AUTHORIZATION TO OBTAIN INFORMATION
By this form, I authorize any licensed physician, medical practitioner, clinic, hospital, other medical or medically-related facility, the Veterans Administration, MIB, an employer, consumer reporting agency, any person, organization, other institution or other insurance companies that have records or knowledge about me or any children to be insured (if applicable) to release this information to The American Home Life Insurance Company. This information may be about: (a) employment; (b) occupation; (c) avocations; (d) other insurance coverage; (e) driving record; (f) age; (g) prescription drug usage; (h) any medical history, condition, care or advice relative to the Proposed Insured's physical or mental health; and (i) other personal characteristics.
This AUTHORIZATION extends to information on the use of alcohol, drugs and tobacco; and the diagnosis or treatment of HIV (the virus that causes AIDS) infection or other sexually transmitted disease. I understand that this information will be used by The American Home Life Insurance Company, its representatives or reinsurers in the evaluation of this application to determine eligibility for insurance and/or to investigate claims. The American Home Life Insurance Company or its representatives may release information covered by this AUTHORIZATION to the American Home Agent(s) listed in my application for insurance, to its subsidiaries, reinsurers, the MIB, or other insurance companies.
The American Home Life Insurance Company may also release this information to others who I authorize in writing or as allowed by law. This AUTHORIZATION may be used for the period of time allowed by law in the state where the policy is delivered or issued for delivery from the date signed below unless sooner revoked. I may revoke this AUTHORIZATION at any time by notifying The American Home Life Insurance Company in writing at Underwriting Department, The American Home Life Insurance Company, P.O. Box 1497, Topeka, KS 66601.
My revocation will not be effective to the extent The American Home Life Insurance Company, its reinsurers, or any other person already has disclosed or collected information or taken other action in reliance on the AUTHORIZATION. I understand that my application for insurance will not be considered unless this AUTHORIZATION is signed and dated. The information The American Home Life Insurance Company or its reinsurers obtains through this AUTHORIZATION may become subject to further disclosure, as required by law. 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 except as authorized by me or as required by law. I agree that a photocopy of this AUTHORIZATION is as valid as the original. I understand that I have the right to receive a copy of this AUTHORIZATION upon request.