Individual Life Insurance Application
Please Print Clearly
Proposed Insured
Full Name
*
Sex:
A
M
B
F
Address:
*
City/State/ZIP:
*
Date of Birth:
*
-
-
Age:
Social Security Number:
Email
*
Email
Phone Number
*
Plan and Payment Information
Funding Option
A
Check
B
EFT Payment
Initial Premium
*
Please ensure that the amount entered is a whole number, with no decimals.
Bank Account Information
Only complete if EFT Payment is selected
Bank Name
*
Bank Name
Account Type
*
A
Checking
B
Savings
Routing Number
*
Routing Number
Account Number
*
Account Number
Account Owner
*
Account Owner
Date Signed
*
-
-
Date Signed
I authorize that I have read and agree to the Premium Payment Disclosure found on page 3 of this application. I authorize ELCO Mutual to make a one-time withdrawal from my bank account to fund this life insurance policy:
*
Enter the Initials of Proposed Owner above
Beneficiary & Trust Information
Please submit any additional information on a separate sheet
Trust Assignment: I agree to the Terms of the Irrevocable Assignment found on page 3 of this application and irrevocably assign the ownership rights of this policy to the trust selected
*
Enter Initials of Proposed Owner above
Applicant Signatures
Agreements and Acknowledgments: To the best of my knowledge and belief, the above information is true and complete and I agree to all authorizations and disclosures included. All statements made are representations and not warranties. I understand that no insurance will be effective until this form is approved and the Policy is issued while the Insured is living. I acknowledge that the Policy applied for provides funds at the time of death which may be used for the purchase of funeral services and merchandise, but does not provide specific funeral services and merchandise. It is not an agreement with a funeral establishment. I understand that any information provided regarding the cost of funeral services was provided as general consumer information only. No representations were made that specific merchandise and/or service have been purchased or will be provided at the time of death. If I am the Owner for insurance on the life of the Proposed Insured, I certify that I have an insurable interest in his or her life. I acknowledge that I have read the fraud warning statement on this form.
Signed at City State
*
Signed at City State
Signature of Proposed Insured
*
Type
Date Signed
*
-
-
Date Signed
Agent’s Statement and Signature(s)
I certify that any information recorded by me on this form is true and accurate to the best of my knowledge.
Date Signed by the agent
*
-
-
Proxy
Do you hereby constitute and appoint the Proxy Committee of ELCO Mutual Life and Annuity, as established in the bylaws, as your lawful attorney and proxy and in your name and stead hereby authorize and empower it to cast your vote at any meeting of the policyholders of the company? This proxy shall continue in force except when you are present in person or revoke it by giving the Company written notice in accordance with the ELCO Mutual Life and Annuity bylaws.
Proposed Owner’s Signature
*
Type
Date Signed
*
-
-
Remarks
For additional questions about the information entered on this form, please contact:
Name:
*
Phone #:
*
Text4
Email:
*
Text5
Relationship:
*
Text6
Premium Payment Disclosure
Electronic Check Disclosure: When you provide a check as payment, you authorize ELCO Mutual Life and Annuity to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. When we use the information from your check to make an electronic fund transfer, the funds may be withdrawn from your account on the same day we receive your payment, and you will not receive your check back from your financial institution. In the event that the payment is not honored, ELCO Mutual Life and Annuity reserves the right to re-present the transaction.
Assignor Signature(s)
*
Type
Date Signed
*
-
-
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