California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 6.9 - Standard Credit Life and Credit Disability Policy Forms › Section 2249.14 - Sample Certificate (Identification Number 11)

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Insurer's Name and Complete Address
Called We or Us
SCHEDULE
Primary Borrower, called you, and Address
Co-Borrower, also called you
Source Code
Creditor Beneficiary and Insurance License Number
Class of Business
Secondary Beneficiary
Term of Insurance
Effective Date
Original Amount of Life Insurance
Scheduled Expiration Date
Monthly Loan Payment
Monthly Total Disability Benefit
Decreasing Life: Single ( ) joint (
							 )
Premium:
Disability: 30-day Elimination
							 Period
Premium:
Total Premium:
Maximum Monthly Disability Benefit:
Maximum Amount of Life Insurance:
Group Policy Number
Certificate Number
APPLICATION OF BORROWER
You are applying for the credit insurance marked above,
					 Your signature below means that you agree that:
1. You are not eligible for insurance if you
				  have reached your 65th birthday.
2.
				  You are eligible for disability insurance only if you are working for wages or
				  profit 30 hours a week or more on the Effective Date.
3. Only the Primary Borrower is eligible for
				  disability insurance.
DISABILITY INSURANCE MAY NOT COVER CONDITIONS FOR WHICH YOU
					 HAVE SEEN A DOCTOR OR A CHIROPRACTOR IN THE LAST SIX MONTHS. (Refer to "Total
					 Disabilities Not Covered" in your certificate for details.)
___________________________
Date
Primary
							 Borrower
Age
___________________________
Co-Borrower
Age
CERTIFICATE OF INSURANCE
You can cancel this insurance at any time by telling the
					 creditor that you want to do so. You will get back ALL the premium you paid for
					 this insurance if you tell us or the creditor to cancel it within 30 days after
					 you receive this certificate. If you cancel this insurance after 30 days, you
					 will not get back all the premium that you paid.
If you have a question, problem or complaint about
					 this insurance, please contact the Creditor Beneficiary at the address and
					 phone number shown in the Schedule or us at (insert address and telephone
					 number of insurer). If we do not resolve your question, problem or complaint to
					 your satisfaction, you may then contact the
California Department of Insurance
300 South Spring Street
Los Angeles, CA 90013
(800)
927-4357 or (213) 897-8921
WHAT YOU GET
We certify that if we have been paid the premium shown in
					 the Schedule you are insured for the coverage shown in the Schedule, subject to
					 the terms of the Group Policy issued to the Creditor.
WHO GETS PAID
Claim payments are made to the irrevocable Creditor
					 Beneficiary named in the Schedule to pay off or reduce your debt. If claim
					 payments are more than the balance of your debt, the difference will be paid to
					 you or to the Secondary Beneficiary named in the Schedule, if any, or to your
					 estate.
WHAT WE WILL PAY
Single Life Insurance Benefit. If you die while you are
					 insured for single life coverage we will pay the amount of insurance in force
					 at the time of your death after we receive proof of your death.
Joint Life Insurance Benefit. If you or your co-borrower
					 die while insured for joint life coverage we will pay the amount of insurance
					 in force at the time you or your co-borrower dies after we receive proof of the
					 death. Only one death benefit is payable under this policy.
Amount of Life Insurance. The amount of life insurance is
					 the scheduled unpaid balance due on the loan on the date of the insured
					 borrower's death. The amount of life insurance does not include any delinquent
					 payments or unearned interest.
Total Disability Insurance Benefit. If you are insured for
					 total disability insurance, we will pay a benefit if you file written proof
					 that you became totally disabled while insured and continue to be totally
					 disabled for more than 30 days. Payment will be calculated from the 31st day of
					 disability. The benefit will be equal to 1/30th of your Monthly Total
					 Disability Benefit in the Schedule for each day of disability to be
					 compensated. Payments will stop when you are not totally disabled any more or
					 when benefits are paid to the Scheduled Expiration Date, whichever comes
					 first.
Definition of Total Disability. During the first 18
					 consecutive months of total disability, total disability means that you are not
					 able to perform the major duties of your occupation because of sickness or
					 accidental injury. After the first 18 consecutive months of total disability,
					 the definition changes and requires that you not be able to perform the duties
					 of any occupation for which you are reasonably qualified by education, training
					 or experience. You will be required to give us written proof of your continuing
					 total disability from time to time.
WHAT WE WON'T PAY
Misstated Age. If you stated you are under 65, but you are
					 not, we will return your premium when we discover this and will not pay any
					 benefits. This also applies to your co-borrower, if you applied for joint life
					 coverage.
Suicide. We won't pay any claim if you commit suicide
					 within 6 months of the Effective Date shown in the Schedule, but we will refund
					 the life insurance premium. This also applies to your co-borrower, if you
					 applied for joint life coverage.
Total Disabilities Not Covered. We won't pay the claim or
					 refund the disability premium if your disability:
1. is a result of normal pregnancy or
				  childbirth or
2. is a result of an
				  intentionally self-inflicted injury or
3. begins within 2 years after the Effective
				  Date as a result of a pre-existing medical condition. A pre-existing medical
				  condition is one for which you saw, or were under treatment by a physician or a
				  chiropractor both within the 6 months before and the 6 months after the
				  Effective Date shown in the Schedule.
WHEN INSURANCE STOPS--REFUNDS
You can stop this insurance at any time. This insurance
					 stops on the Scheduled Expiration Date, or when your loan is paid off, renewed,
					 refinanced or otherwise stops, whichever happens first. If your insurance stops
					 before the Scheduled Expiration Date in the Schedule, you will be given a
					 refund or a credit on your account of unearned premium. This refund or credit
					 will be calculated using a formula approved by the Insurance Commissioner, but
					 refunds or credits of less than $5.00 won't be made.
WHAT THE CONTRACT IS AND HOW YOUR STATEMENTS AFFECT
					 IT
The Group Policy, the Application for the Group Policy, and
					 the attached Application of Borrower are the complete contract of insurance.
					 All statements made by you in your Application are considered to have been made
					 to the best of your knowledge and belief. No statement can be used to void this
					 insurance or deny a claim unless that statement is in your signed Application.
					 After 2 years during your lifetime from the Date in the Application, no
					 statement made by you in your Application can be used to void this insurance or
					 deny a claim. This does not apply to your disability coverage (if any) if that
					 statement was made fraudulently. If you stated in your Application that you are
					 age 65 or older and we do not return your premium within 75 days of the
					 Effective Date, you are insured.
RULES FOR FILING A TOTAL DISABILITY
					 CLAIM
You must write us or our agent about your total disability
					 claim within 30 days after the beginning of your total disability or as soon
					 after that as you can. We will send you claims forms within 15 days after you
					 tell us about the claim. If we don't send the forms in 15 days, you can simply
					 send us written proof of your disability. The proof must show the date and the
					 cause of the total disability and how serious it is, and it must be signed by a
					 physician or a chiropractor. The proof of total disability must be sent to us
					 no later than 90 days after the end of each period for which a total disability
					 benefit is payable. If it is impossible to file within 90 days, you must file
					 as soon as you can. Unless you have been legally incapable of filing the proof
					 of total disability, we won't accept it if it is filed after one year from the
					 time if should have been filed. You can't start any legal action until 60 days
					 after you send us the proof of your total disability, and you can't start any
					 legal action more than 3 years after the proof is filed.
RULES FOR FILING A LIFE CLAIM
We must be given a certified copy of the death certificate
					 as proof of a life claim.
PHYSICAL EXAMINATION AND AUTOPSY
We at our own expense have the right, and you must allow us
					 the opportunity, to examine your person as often as is reasonably required
					 while a claim is pending and to make an autopsy in case of death, if it is not
					 forbidden by law.
1. Amendment
					 of paragraph captioned "When Insurance Stops-Refunds" filed 12-29-78;
					 designated effective 4-1-79 and for technical reasons, printed in Register 79,
					 No. 2.
2. Amendment filed 7-25-83; effective thirtieth day
					 thereafter (Register 83, No. 31).
3. Amendment filed 5-23-85;
					 effective thirtieth day thereafter (Register 85, No. 21).
4.
					 Amendment of section heading, section and NOTE filed 10-2-2006; operative
					 11-1-2006 (Register 2006, No. 40).
Note: Authority cited: Sections
						779.21 and
						779.27,
						Insurance Code. Reference: Sections
						510,
						779.2,
						779.3,
						779.4,
						779.6,
						779.14,
						779.27,
						779.30,
						779.31,
						1758.99,
						10113,
						10113.5,
						10203.5,
						10203.55,
						10207,
						10208,
						10209,
						10127.5,
						10320,
						10350-10350.3, 10350.5-10350.7,
						10350.10, 10350.11, 10369.1 and 10369. 10, Insurance Code; and Section
						120980(f),
						Health and Safety Code.