South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:06 - Credit life, health, and unemployment insurance › Appendix B - Sample application form

Current through Register Vol. 51, page 10, July 15, 2024
APPENDIX B
Insured Debtor
John Doe Box 555 Anywhere, USA, 55555
Date of Birth
Age
Certificate Number
Joint Insured Debtor
Creditor (Beneficiary) (Name and Address)
ABC Bank 555 AVENUE Anywhere, USA 55555
Creditors Insurance Account No
Assignee (Name and Address)
Monthly Payment
Annual Simple Interest Rate
Second Beneficiary
Relationship
EFFECTIVE DATE
EXPIRY DATE
Days to 1st Payment
COVERAGES
INITIAL AMOUNT OF INSURANCE
PREMIUMS
TERM IN MONTHS
[] Gross or
[] NET
[] W. Dism
[] W/O Dism
[] Decreasing Term
[] Periodic Decreasing Term
$ 5,400.00
$ -
36
[] Jt. Decreasing Term
[] Jt. Periodic Decreasing Term
[] Level Term
[] Jt. Level Term
$ 11,197.00
$ -
36
35
Payments of $
$150.00
$ 5,400.00
$ -
36
Final Payment of $
$11,347.51
[$150.00 Monthly Disability Benefit]
$ -
PREMIUM <-TOTAL
[] Disability Coverage (Insured Debtor Only)
WAITING PERIOD ELIMINATION PERIOD
[] 7 Days
Retrospective
0 Days
[] 14 Days
Retroactive
0 Days
Maximum Monthly Disability (per debtor)
Maximum Monthly Disability (per debtor)
Maximum Term
Maximum Issue Age
65
Inclusive
[] 30 Days
Retroactive
0 Days
[] 14 Days
Non-Retro
14 Days
[] 30 Days
Non-Retro
30 Days
$1000.00 (Ages 18-65)
$100,000.00 Ages 18-65)
120 Months
DEATH CLAIM STATEMENT- INSTRUCTIONS: Creditor Policyholder should complete the statement below and return with the following documents: 1. Certified copy of the Death Certificate showing cause of death; 2. Copy of the conditional sales contract or note covered by the Insurance; 3. Copy of the Policy or Certificate Issued to the deceased. This completed form, together with the documents specified above, should be sent to:
ABC ASSURANCE COMPANY Insurance Division, 555 Boulevard, Anywhere, USA, 55555-555
1. Name of Insured
2. Certificate No. (or individual Policy No.)
Date of Loan
for Term of
Mos.
3&&&&&&&&&&&&&
Original Amount Insured
&&&&&&&&&&&.
$ -
4&&&&&&&&&&&&&
Less Amount Paid
&&&&&&&&&&&.
$ -
To comply with certain State Laws, our payoff to a creditor may be for the net amount due (Gross amount less unearned interest and/or advance payments). Please advise us of this amount. Any remaining balance is payable to the second beneficiary if named, otherwise to the Debtors Estate.
5&&&&&&&&&&&&&
Less Unearned Interest
&&&&&&.&&&&
$ -
6&&&&&&&&&&&&&
Less Unearned A & H Premium (Life Premium Earned)
&&&&&&&&&&&
$ -
7&&&&&&&&&&&&&
Balance Due
&&&&&&&&&&&
$ -
8&&&&&&&&&&&&&.
Number of Monthly Payments in Default at Death
9&&&&&&&&&&&&&.
Creditor Policyholder's Name
"Insurance Account No."
Street Address
City
State
Zip Code
I hereby certify that the above answers are complete and true, and the balance due is the amount in line 7.
Date:
By:
Title:
PREMIUM REFUND RECEIPT SCHEDULE
Send to: P.O. Box 555 Anywhere, USA 55555-555
MO.
DAY
YEAR
LIFE
DISABILITY
TOTAL
DATE OF CANCELLATION
PERCENT UNEARNED
%
%
POLICY CERTIFICATE WAS IN FORCE
MONTHS
AMOUNT OF REFUND
%
%
I understand, hereby request cancellation of the above numbered certificate or policy as of 12:00 noon, Standard Time, as of the date of cancellation shown above. I hereby acknowledge receipt of the amount of refund shown above as a full refund of the unearned portion of the premium and hereby release ABC Company from all further liability under said certificate (s) or policy(ies)) as the case may be
Date
AGENT OR WITNESS
SIGNATURE OF INSURED
Name of Creditor
Address