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

Current through Register Vol. 51, page 10, July 15, 2024
APPENDIX A
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
$ 28,615.00
$ -
59
[] Jt. Decreasing Term
[] Jt. Periodic Decreasing Term
[] Level Term
[] Jt. Level Term
$ 22,352.47
$ -
60
59
Payments of $
$485.00
$ 28,615.00
$ -
59
Final Payment of $
$22,352.47
[$485.00 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
Application for Insurance
ABC ASSURANCE COMPANY
(Called We)
Anywhere, USA 55555-5555
I am indebted to the above named Creditor for the above sum and for the security of payment of said debt. I hereby apply for credit insurance covering the amount of said debt as indicated above
I represent that the answers on this application are true and complete to the best of my knowledge and belief. They are the basis on which insurance requested by me may be issued.
Insured
Debtor
Joint Insured
Debtor
Yes
No
Yes
No
[]
[]
1. Are you under age 66?
[]
[]
[]
[]
2. Are you in good health as far as you know and believe?
[]
[]
[]
[]
3. Are you actively and gainfully employed for wage or profit on a full time basis
N/A
[]
[]
4. During the past 5 years have you been treated for, or been told you had, any of the following conditions (Please Circle) High Blood Pressure; Heart Disease; Cancer or Tumor; Diabetes; Stroke; Disease of Liver or Kidney; Alcoholism; Drug Addiction; any Brain, Nervous System or Mental/Neurological Disorder; Acquired Immune Deficiency Syndrome (AIDS).
[]
[]
I understand that if the aforesaid representations are false and untrue, the Insurance Company's Liability shall be limited to the return of the premium paid for said coverage (subject to the 2-year incontestability provision).
I further understand that the insurance prepaid for is not compulsory, nor a condition precedent to any loan or credit transaction. I certify that I have been given the option to purchase such credit insurance from any insurer or agent of my choice. I freely chose the insurer and agent to whom this application is made. I declare that I have read or had read to me this statement before signing.
Date
Signature of Insured Debtor
Witness
Signature of Joint Insured Debtor
Upon Acceptance by the Insurer, the insurance shall become effective as of the effective date shown above.