IMPORTANT NOTICE |
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DEFINITION |
REPLACEMENT is any transaction where, in connection with the purchase of New Insurance or a New Annuity, you LAPSE, SURRENDER, CONVERT to Paid-up Insurance, Place on Extended Term, or BORROW all or part of the policy loan values on an existing insurance policy or an annuity. (See reverse side for DEFINITIONS.) |
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IF YOU INTEND TO REPLACE COVERAGE |
In connection with the purchase of this insurance or annuity, if you have REPLACED or intend to REPLACE your present life insurance coverage or annuity(ies), you should be certain that you understand all the relevant factors involved. |
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You should BE AWARE that you may be required to provide EVIDENCE OF INSURABILITY and |
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(1) If your HEALTH condition has CHANGED since the application was taken on your present policies, you may be required to pay ADDITIONAL PREMIUMS under the NEW POLICY, or be DENIED coverage. |
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(2) Your present occupation or activities may not be covered or could require additional premiums. |
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(3) The INCONTESTABLE and SUICIDE CLAUSE will begin anew in a new policy. This could RESULT in a CLAIM under the new policy BEING DENIED that would otherwise have been paid. |
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(4) Current law MAY NOT REQUIRE your present insurer(s) to REFUND any premiums. |
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(5) It is to your advantage to OBTAIN INFORMATION regarding your existing policies or annuity contracts from the insurer or agent from whom you purchased the policy or annuity contract. |
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(If you are purchasing an annuity, clauses (1), (2), and (3) above would not apply to the new annuity contract.) |
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THE INSURANCE OR ANNUITY I INTEND TO PURCHASE FROM ...................................... INSURANCE CO. MAY REPLACE OR ALTER EXISTING LIFE INSURANCE POLICY(IES) OR ANNUITY CONTRACT(S). |
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The following policy(ies) or annuity contract(s) may be replaced as a result of this transaction: |
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Insured |
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as it appears on the policy |
as it appears on the policy |
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or contract |
or contract |
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Policy or contract number |
Insured birthdate |
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The proposed policy or contract is: |
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$
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type of policy- or contract-generic name |
face amount |
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signature of applicant |
date |
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address of applicant
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state |
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I certify that this form was given to and completed by |
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(applicant-please print or type) |
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prior to taking an application and that I am leaving a signed copy for the applicant. |
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agent's signature |
date |
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address |
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city |
state |
DEFINITION |
REPLACEMENT is any transaction where, in connection with the purchase of New Insurance or a New Annuity, you LAPSE, SURRENDER, CONVERT to Paid-up Insurance, Place on Extended Term, or BORROW all or part of the policy loan values on an existing insurance policy or an annuity. (See reverse side for DEFINITIONS.) |
||
IF YOU INTEND TO REPLACE COVERAGE |
In connection with the purchase of this insurance or annuity, if you have REPLACED or intend to REPLACE your present life insurance coverage or annuity(ies), you should be certain that you understand all the relevant factors involved. |
||
You should BE AWARE that you may be required to provide Evidence of insurability and |
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(1) If your HEALTH condition has CHANGED since the application was taken on your present policies, you may be required to pay ADDITIONAL PREMIUMS under the NEW POLICY, or be DENIED coverage. |
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(2) Your present occupation or activities may not be covered or could require additional premiums. |
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(3) The INCONTESTABLE and SUICIDE CLAUSE will begin anew in a new policy. This could RESULT in a CLAIM under the new policy BEING DENIED that would otherwise have been paid. |
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(4) Current law DOES NOT REQUIRE your present insurer(s) to REFUND any premiums. |
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(5) It may be to your advantage to OBTAIN INFORMATION regarding your existing policies or annuity contracts from the insurer or agent from whom you purchased the policy or annuity contract. |
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(If an annuity is being purchased, Items (1), (2) and (3) above would not apply to the new contract.) |
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CAUTION |
If after studying the information made available to you, you decide to replace your existing life insurance or annuity with our policy or annuity contract, you are urged not to take action to terminate or alter your existing coverage or annuity(ies) until after you have been issued the new policy or annuity contract, examined it and found it to be acceptable to you. If you should terminate or otherwise materially alter your existing coverage or annuity(ies) and fail to qualify for the life insurance for which you have applied, you may find yourself unable to purchase other life insurance or be able to purchase it only at substantially higher rates. |
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INSURER'S MAILING DATE:
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Official Publication of the State of Minnesota
Revisor of Statutes