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 2249.11 - Application Blocks

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
AP 1
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
AP 2
APPLICATION OF BORROWER
You are applying for credit insurance marked above. Your
					 signature below means that you agree that you are not eligible for insurance if
					 you have reached your 65th birthday.
___________________________
Date
Primary
							 Borrower
Age
___________________________
Co-Borrower
Age
AP 3
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
				  life or 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
AP 4
APPLICATION OF BORROWER
You are applying for the credit insurance marked above.
					 Your signature below means that:
1.
				  You are not eligible for insurance if you have reached your 65th
				  birthday.
2. Your co-borrower is
				  not eligible for life or disability insurance.
___________________________
Date
Primary
							 Borrower
Age
AP 5
APPLICATION FOR CREDIT
					 INSURANCE
You are applying for the 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 do not have to buy any life insurance to be eligible for disability
				  coverage, or vice versa.
3. You are
				  eligible for disability coverage only if you are working for wages or profit,
				  for 30 hours a week or more, on the Effective Date.
4. 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
THIS INSURANCE MAY BE ISSUED ONLY TO COVER BORROWERS WHO
					 HAVE A LOAN UNDER THE INDUSTRIAL LOAN LAW OR THE CALIFORNIA FINANCE LENDERS
					 LAW.
AP 6
APPLICATION OF BORROWER
You are applying for the credit insurance marked above.
					 Your signature below means that you agree that you are not eligible for
					 insurance if you have reached your 65th birthday.
__________________________________
Date
Primary
							 Borrower
Age
___________________________
Co-Borrower
Age
THIS INSURANCE MAY BE ISSUED ONLY TO COVER BORROWERS WHO
					 HAVE A LOAN UNDER THE INDUSTRIAL LOAN LAW OR THE CALIFORNIA FINANCE LENDERS
					 LAW.
AP 7
APPLICATION FOR CREDIT
					 INSURANCE
You are applying for the 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 do not have to buy any life insurance to be eligible for disability
				  coverage, or vice versa.
3. You are
				  eligible for disability coverage only if you are working for wages or profit,
				  for 30 hours a week or more, on the Effective Date.
4. Only the Primary Borrower is eligible for
				  life or 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
THIS INSURANCE MAY BE ISSUED ONLY TO COVER BORROWERS WHO
					 HAVE A LOAN UNDER THE INDUSTRIAL LOAN LAW OR THE CALIFORNIA FINANCE LENDERS
					 LAW.
AP 8
APPLICATION FOR CREDIT INSURANCE
You are applying for the insurance marked above. Your
					 signature below means that you agree that you are not eligible for insurance if
					 you have reached your 65th birthday.
___________________________
Date
Primary
							 Borrower
Age
THIS INSURANCE MAY BE ISSUED ONLY TO COVER BORROWERS WHO
					 HAVE A LOAN UNDER THE INDUSTRIAL LOAN LAW OR THE CALIFORNIA FINANCE LENDERS
					 LAW.
AP 10
APPLICATION OF BORROWER
You are applying for the credit insurance marked above and
					 authorizing the Creditor to add the charges for insurance to your loan each
					 month as they become due. You ha e the right to stop this authorization Your
					 signature below means that you agree that:
1. You are eligible for insurance as to each
				  advance only if you are working for wages or profit 30 hours a week or more on
				  the date you sign for the advance. If you are not, that particular advance will
				  not be insured until you return to work.
You are insured only for advances actually received by you.
					 You are not insured for any unused credit which may be available to
					 you.
2. Each month the
				  insurance charge is calculated by multiplying the insured outstanding principal
				  balance of your loan on the billing date by the rate shown in the Schedule.
We can change the rate later on. But if we do, we will let
					 you know in advance. The new rate will apply only to charges for insurance made
					 after the date of the rate change.
3. Only the Primary Borrower is eligible for
				  disability insurance.
4. Neither
				  you nor your co-borrower are eligible for insurance after you have reached your
				  65th birthday, and insurance will also stop when you reach that age.
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
Date
							 of Birth
____________________________________
Co-Borrower
Date of
							 Birth
AP 11
APPLICATION OF BORROWER
You are applying for the credit insurance marked above and
					 authorizing the Creditor to add the charges for insurance to your loan each
					 month as they become due. You have the right to stop this authorization. Your
					 signature below means that you agree that:
1. You are insured only for advances actually
				  received by you. You are not insured for any unused credit which may be
				  available to you.
2. Each month the
				  insurance charge is calculated by multiplying the insured outstanding principal
				  balance of your loan on the billing date by the rate shown in the Schedule.
We can change the rate later on. But if we do, we will let
					 you know in advance. The new rate will apply only to charges made for insurance
					 after the date of the rate change.
3. Neither you nor your co-borrower are
				  eligible for insurance after you have reached your 65th birthday, and the
				  insurance will also stop on the last day of the month during which you reach
				  that age.
___________________________________________
Date
Primary Borrower
Date
							 of Birth
____________________________________
Co-Borrower
Date of
							 Birth
AP 12
APPLICATION OF BORROWER
You are applying for the credit insurance marked above and
					 authorizing the Creditor to add the charges for insurance to your loan each
					 month as they become due. You have the right to stop this authorization. Your
					 signature below means that you agree that:
1. You are insured for advances actually
				  received by you. You are not insured for any unused credit which may be
				  available to you.
2. Each month the
				  insurance charge is calculated by multiplying the insured outstanding principal
				  balance of your loan on the billing date by the rate shown in the Schedule.
We can change the rate later on. But if we do, we will let
					 you know in advance. The new rate will apply only to charges made for insurance
					 after the date of the rate change.
3. You are not eligible for insurance after
				  you have reached your 65th birthday, and the insurance will also stop on the
				  last day of the month during which you reach that age.
______________________________
Date
Primary Borrower
Date
							 of Birth
AP 13
APPLICATION OF BORROWER
You are applying for the credit insurance marked above.
					 Your signature below means that you agree that the maximum amount of life
					 insurance is $__________ for ages $__________for ages and $__________for
					 ages__________
_____________________________________
Date
Primary
							 Borrower
Age
_____________________________
Co-Borrower
Age
AP 14
APPLICATION OF BORROWER
You are applying for the credit insurance marked above.
					 Your signature below means that you agree that:
1. The maximum amount of life insurance is
				  $__________for ages__________ $__________ for ages__________and $__________for
				  ages__________.
2. The maximum
				  monthly total disability benefit is $__________for ages,
$__________for ages__________and
$__________for ages.
3. Only the Primary Borrower is eligible for
				  disability insurance.
4. You are
				  eligible for disability insurance only if you are working for wages or profit
				  30 hours a week or more.
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
AP 15
APPLICATION OF BORROWER
You are applying for the credit insurance marked above.
					 Your signature below means that you agree that the maximum amount of life
					 insurance is $__________ for ages__________,$__________ for ages__________and
					 $__________for ages__________
___________________________
Date
Primary
							 Borrower
Age
AP 16
APPLICATION OF BORROWER
You are applying for the credit insurance marked above.
					 Your signature below means that you agree that:
1. The maximum monthly total disability
				  benefit is $__________ for ages__________, $__________ for ages__________ and
				  $__________ for ages__________.
2.
				  Only the Primary Borrower is eligible for disability insurance.
3. You are eligible for disability insurance
				  only if you are working for wages or profit 30 hours a week or more.
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
AP 17
APPLICATION OF BORROWER
You are applying for the credit insurance marked above.
					 Your signature below means that you agree that:
1. The maximum amount of life insurance is
				  $__________for ages__________, $__________ for ages__________ and $__________
				  for ages__________.
2. The maximum
				  monthly total disability benefit is $__________for ages__________$__________for
				  ages__________, and $__________ for ages__________.
3. Only the Primary Borrower is eligible for
				  disability insurance.
4. You are
				  eligible for disability insurance only if you are working for wages or profit
				  30 hours a week or more.
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
AP 18
APPLICATION OF BORROWER
You are applying for the credit insurance marked above and
					 authorizing the Creditor to add the charges for insurance to your loan each
					 month as they become due. You have the right to stop this authorization. Your
					 signature below means that you agree that:
1. You are eligible for insurance as to each
				  advance only if you are working for wages or profit 30 hours a week or more on
				  the date you sign for the advance. If you are not, that particular advance will
				  not be insured until you return to work.
You are insured only for advances actually received by you.
					 You are not insured for any unused credit which may be available to
					 you.
2. Each month the
				  insurance charge is calculated by multiplying the insured outstanding principal
				  balance of your loan on the billing date by the rate shown in the Schedule.
We can change the rate later on. But if we do, we will let
					 you know in advance. The new rate will apply only to charges for insurance made
					 after the date of the rate change.
3. Only the Primary Borrower is eligible for
				  life or disability insurance.
4.
				  You are not eligible for insurance after you have reached your 65th birthday
				  and insurance will also stop when you reach that age.
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
Date
							 of Birth
AP 19
APPLICATION OF BORROWER
You are applying for the credit insurance marked above and
					 authorizing the Creditor to add the charges for insurance to your loan each
					 month as they become due. You have the right to stop this authorization. Your
					 signature below means that you agree that:
1. You are eligible for insurance as to each
				  advance only if you are working for wages or profit 30 hours a week or more on
				  the date you sign for the advance. If you are not, that particular advance will
				  not be insured until you return to work.
You are insured only for advances actually received by you.
					 You are not insured for any unused credit which may be available to
					 you.
2. Each month the
				  insurance charge is calculated by multiplying the insured outstanding principal
				  balance of your loan on the billing date by the rate shown in the Schedule.
We can change the rate later on. But if we do, we will let
					 you know in advance. The new rate will apply only to charges for insurance made
					 after the date of the rate change.
3. Only the Primary Borrower is eligible for
				  disability insurance.
4. You are
				  not eligible for insurance after you have reached your 65th birthday and
				  insurance will also stop when you reach that age.
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
Date
							 of Birth
AP 20
MEDICAL APPLICATION OF
					 BORROWER
You are applying for the credit insurance marked above. You
					 should understand that untruthful answers to these questions may cancel your
					 insurance protection.
1. Date of
				  Birth_______________ Place of Birth_______________ Height_____ft._____ in.
				  Weight_____lbs. Sex_____M_____F.
___________________________
2. Occupation
______________________________
Employed By:
..........................
3. Are you now working 30 hours a week or
				  more at
your occupation?
Yes___No___
..........................
4. Are you now in good health and free from
				  the effects
of any illness or injury?
Yes___No___
5. Have you, during the last five years, had,
				  or been advised to have, advice or treatment for any of the following:
..........................
a) Cancer, Tumor, Ulcer, Goiter, Thyroid,
				  Asthma,
Tuberculosis, Leukemia
Yes___No___
..........................
b) Mental or Nervous Disorder, Paralysis or
Convulsions
Yes___No___
..........................
c) High Blood Pressure, Rheumatic Fever,
				  Heart
Disease, Stroke
Yes___No___
..........................
d) Diabetes, Sugar/Albumin in Urine, Prostate
Disorder
Yes___No___
..........................
e) Impairment of Sight, Speech or Hearing
Yes___No___
..........................
f) Disease of Liver, Gall Bladder, Kidneys,
				  or Lungs
Yes___No___
..........................
g) Disease or impairment of Bones, Joints,
				  Glands or
Muscles
Yes___No___
..........................
h) Strained Back, Slipped Disc or Sciatica
Yes___No___
..........................
i) Drug Addiction or Alcoholism
Yes___No___
..........................