LIBERTY BANKERS
DISCLOSURES/or PAPERLESS APPLICATION PROCESS – GENERIC
Included are the three required disclosures (Fair Credit, MIB, and HIPAA) that must be read and given to your applicant prior to the point of sale telephone interview. Your client will be asked to verify that these were read to them. In addition, the states of Alabama, California, and Pennsylvania require state specific disclosures that must be completed, signed, and faxed to New Business prior to issuing a policy.
FAIR CREDIT REPORTING ACT PRE-NOTIFICATION FORM.
Thank you for considering Liberty Bankers/The Capitol Life Insurance Company as your insurance carrier. Your application will be processed as quickly as possible. Public Law 91-5088 requires that we advise you that an investigative consumer report may be made in connection with this application which will provide applicable information concerning character, general reputation, personal characteristics and mode of living. The information for this report may be obtained through personal interviews with friends, neighbors, and associates. You are entitled to be interviewed in connection with an investigative consumer report; and, you have the right to receive a copy of any investigative consumer report by making a written request within a reasonable period of time.
NOTICE TO APPLICANTS FOR INSURANCE.
Information regarding your insurability will be treated as confidential. Liberty Bankers/The Capitol Life Insurance Company, or its reinsurer(s), may, however, make a brief report of my protected health information to the MIB, Inc., a not for profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB, Inc. member company for life and health insurance coverage, or a claim for benefits is submitted to such a company, the MIB, Inc., upon request from you, will arrange disclosure of any information it may have in your file. If you question the accuracy of information in the MIB's file, you may contact the MIB, Inc. and seek a correction in accordance with the procedure set forth in the Federal Fair Credit Reporting Act.
The address of the MIB's information office is 50 Braintree Hill, Suite 400, Braintree, Massachusetts, 02184, telephone 1-866-692-6901, web address: www.mib.com. Liberty Bankers/The Capitol Life Insurance Company, or its reinsurer(s), may also release information in its file to other life insurance companies to whom you may also apply for life or health insurance, or to whom a claim for benefits may be submitted.
CONDITIONAL RECEIPT - (Cross through if payment is NOT received).
NO INSURANCE WILL BECOME EFFECTIVE PRIOR TO DELIVERY, UNLESS THE FOLLOWING CONDITIONS HAVE BEEN FULFILLED EXACTLY: INSURANCE ISSUED BASED ON THE APPLICATION WILL TAKE EFFECT ONLY IF THESE CONDITIONS ARE MET:
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That on the effective date the Proposed Insured is insurable as a standard risk under the Company's rules for the plan amount and premium rate applied for.
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That the sum paid is equal to the FULL FIRST PREMIUM for the policy applied for.
INSURANCE ISSUED BASED ON THE APPLICATION WILL TAKE EFFECT ON THE LATEST OF:
(a) Date of the application; or
(b) Date requested in the application; or(c) Date of the last of any medical examinations or tests required under the rules and practices of the Company.
AUTHORIZATION TO OBTAIN, RELEASE AND DISCLOSE MEDICAL INFORMATION
I hereby authorize any: medical practitioner, physician, hospital, clinic, pharmacy benefit manager, or other medical related facility, insurance company, insurance support organization, business partner, pharmacy, government agency, group policy holder, employer, benefit plan administrator, the MIB, Inc., the Department of Motor Vehicle Registration, and paramedical facility to provide to LIBERTY
BANKERS LIFE INSURANCE COMPANY, or to any agent, attorney, consumer reporting agency or independent administrator, including medical record retrieval services or pharmaceutical services, acting on LIBERTY BANKERS LIFE INSURANCE COMPANY'S or its reinsurers' behalf, information concerning advice, care, or treatment sought by or provided to me and/or any other applicant for coverage, including information relating to medical history, medical conditions, treatment, hospitalizations or confinements, ailments, pharmacy prescription drugs, and/or drug, alcohol or tobacco usage of the applicant(s).
It is understood that LIBERTY BANKERS LIFE underwriters, claim examiners, reinsurers, attorneys, or the medical director may disclose such health information to the aforementioned parties for purposes of underwriting, compliance, record clarification or explanation, or in response to litigation, summons, or subpoenas. I understand that after this information is disclosed, the recipient may re-disclose it resulting in loss of protection by federal regulations. I authorize LIBERTY BANKERS LIFE INSURANCE COMPANY, or its reinsurers, to make a brief report of my protected health information to the MIB, Inc.
I understand that: such information will be used by LIBERTY BANKERS LIFE INSURANCE COMPANY for underwriting and insurability determination I may refuse to sign this authorization and that my refusal to sign will affect my ability to obtain life insurance coverage; a picture copy or photocopy of this authorization shall be as valid as the original; and any authorized representative of the proposed insured is entitled to receive a copy of this authorization upon request.
This authorization is valid from the date signed for a duration of 24 months. I understand I may revoke the authorization at any time, except to the extent that action has been taken in reliance on this authorization, by sending written notice to the Life Underwriting Department of LIBERTY BANKERS LIFE INSURANCE COMPANY, P. O. Box 224, Brownwood, Texas 76804. I may inspect or copy any information used or disclosed under this authorization, if signed.
LIBERTY BANKERS LIFE INSURANCE COMPANY ACCELERATED DEATH BENEFIT RIDER NOTICE: Death benefits, premium payments, and cash surrender values, if any, will be reduced upon payment of an accelerated benefit. The accelerated benefits offered under this rider may or may not qualify for favorable tax treatment under the Internal Revenue Code of 1986. Whether such benefits qualify depends on factors such as your life expectancy at the time benefits are accelerated or whether you use the benefits to pay for necessary long-term care expenses, such as nursing home care. If the acceleration of benefits qualifies for favorable tax treatment, the benefits will be excluded from your income and not subject to federal taxation. However, accelerated benefit payments may be taxable by your state. Tax laws relating to accelerated benefits are complex. You should consult a qualified tax advisor for specific information. Receipt of an accelerated benefit payment may adversely affect your, your spouse's or your family's eligibility for medical assistance (Medicaid), Aid to Families with Dependent Children (AFDC), supplementary social security income (SSI), and drug assistance or other public assistance programs. You should consult with a qualified advisor and with social services agencies regarding how receipt of such payment may affect eligibility for such programs.
LIBERTY BANKERS LIFE INSURANCE COMPANY ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT RIDER BENEFITS
Liberty Bankers Life Insurance Company agrees to pay the sum specified per the table below, in accordance with the terms of the policy and this rider. The AD&D Sum Insured is shown on the Schedule Page of the policy. The amount payable on this rider will be included in the proceeds of the policy. The proceeds will be paid to the beneficiary upon receipt, at the Company’s Home Office, of due proof that the death of the Insured:
A) was the direct result of an accidental bodily injury, independent of all causes, which is supported by an autopsy (except in the case of drowning or of internal injuries revealed by an autopsy, or smoke inhalation due to fire); and
B) such injury occurred while the policy and this rider were in force; and
C) was not intentionally self-inflicted; and
D) occurred within 180 days from the date of such injury.
If within 180 days following an accident causing an Injury (as defined in this rider), the Insured incurs a loss as specified below, We will pay the Owner the sum specified for such loss. We will pay for one loss, the largest loss, if more than one loss is incurred.
GENERAL EXCLUSIONS
The Accidental Death Benefit provided by this rider shall not be payable if his/her death is contributed to, wholly or in part, by any of the following causes:
A) committing, or attempting to commit, suicide or self-destruction, while sane or insane; or
B) intentional self-inflicted injuries, while sane or insane; or
C) physical or mental disease or infirmity of any kind; or
D) medical or surgical treatment of a disease or illness; or
E) travel or flight on, or descent from, any kind of aircraft if the Insured:
1) has any duties aboard such aircraft; or
2) is receiving any kind of training or instructions; or
3) the aircraft is operated by or for any military force; or
F) hang gliding or skydiving; or
G) injuries sustained as the result of war, declared or undeclared, or insurrection; or
H) voluntary participation in a riot or civil disobedience; or
I) committing, or attempting to commit, or participating in a crime, assault, felony or any other illegal act; or
J) voluntary taking of any drug, medication, or sedative unless taken as prescribed by a physician; or (exclusions continued next page) ICC16-LBL-ADD- 0716 Page 2 of 2
K) being under the influence, as described in the laws of the place where the accident occurs, of alcohol, drug or controlled substance; or
L) taking any kind of poison, or the inhaling of any kind of gas voluntarily, unless as a direct result of an occupational accident.
