Baltimore Life Application Disclosures
PLEASE READ AND SIGN:
I understand that if I provide any false or incomplete answers, and/or if the health of the Proposed Insured changes before the policy effective date and I don't notify The Baltimore Life Insurance Company (the Company) of such changes, then benefits may be denied or the policy may be rescinded. My policy will not take effect unless the first premium is paid in full and the application is approved by the Company. I understand that no agent is authorized to advise me that an inaccurate answer is acceptable. When I sign the application, I understand, I am authorizing the MIB Group, Inc. (“MIB”), any medical or medically-related person or facility to provide health and/or treatment information about the proposed Insured to the Company. I understand that such information will be used to determine eligibility for insurance and/or benefits. Any information used will be subject to the Company's Notice of Privacy and Information Practices which is provided with my policy, or upon request. I understand that I may request a copy of this authorization and agree that a photographic copy of this authorization shall be as valid as the original. This authorization shall remain valid for a period of two years and six months from the date it is signed.
WARNING: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim or deceptive statement is guilty of insurance fraud.
APPLICANT(S) PRE-NOTICE
Information regarding your insurability will be treated as confidential. The Company or its reinsurers may, however, make a brief report thereon to the Medical Information Bureau, a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If you apply to another Bureau member company for life or health insurance coverage, or a claim for benefits is submitted to such company, the Bureau, upon request, will supply such company with the information in its file. Upon receipt of a request from you, the Bureau will arrange disclosure to you of any information it may have in your file. If you question the accuracy of information in the Bureau’s file, you may contact the Bureau and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address of the Bureau’s information office is 50 Braintree Hill, Suite 400, Braintree, MA 02184-8734; the telephone number is (866) 692-6901. The Company or its reinsurers may also release information in its file to other life insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted.
Application made at________________ this ______ day of _____________,
MONTHLY AUTOMATIC CHECK AUTHORIZATION
As a convenience to me, I hereby request and authorize you to issue and charge to my account checks drawn on my account by and payable to the order of The Baltimore Life Insurance Company. I agree that your treatment of each check and your rights thereunder shall be the same as if the check was personally signed by me. If any check is dishonored for any reason, I release you from any liability resulting from the dishonor of the check, even if the dishonor results in cancellation of my insurance or annuity policy. Lastly, I agree that this authorization shall remain in effect until written notice of its termination is provided by me to you or until terminated by the Company.
CONDITIONAL RECEIPT
Received from____________________________ the sum of $________________ This receipt is given and accepted with the understanding that the insurance applied for shall go into force when the application is completed, the first premium is paid in full, and the application is approved by the Company while the Proposed Insured’s condition of health is unchanged from the date of the application.
Form 7430-0508(OH)
TAX NOTICE AND CERTIFICATION
CERTIFICATION: Under penalties of perjury, I certify that (1) the number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); (2) I am NOT subject to backup withholding because: a) I am exempt from backup withholding, or b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or c) the IRS has notified me that I am no longer subject to backup withholding; and 3) I am a U.S. person (including a U.S. Resident Alien). Section 6109 of the Internal Revenue Code requires you to provide your correct tax identification number (TIN) to persons who must fi le information returns with the IRS to report interest, dividends and certain other income. We may also disclose this information to other countries under a tax treaty to federal and state agencies to enforce federal non-tax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. The IRS does not require your consent to any provisions of this document other than the certification required to avoid backup withholding.