UNEMPLOYMENT/DISABILITY/LIFE CREDIT INSURANCE 

UNEMPLOYMENT / DISABILITY / LIFE CREDIT INSURANCE  
CHARGEGARD helps keep your credit rating and your credit card account in good standing by making your minimum monthly payments if you lose your job 
involuntarily; become disabled; take an unpaid, employer-approved leave of absence due to family illness, childbirth or adoption, return to military service, or live in a 
federally-declared disaster area until you return to work*   If you die, Chargegard can pay the outstanding balance on your account.* No medical questions or physical exams 
required to enroll. * Maximum benefit for life, unemployment, disability or leave of absence is $10,000. Unemployment, disability and leave of absence coverages are not 
each available in every state. Coverages and rates vary by state. Benefits are based on your balance as of date involuntarily unemployed, disabled, on leave or deceased. 
SUMMARY OF INSURANCE COVERAGES-IMPORTANT INFORMATION ON CHARGEGARD LIMITATIONS, EXCLUSIONS, COSTS:  Upon acceptance of your 
enrollment, you will receive your certificates and/or policies indicating your effective date. Eligibility, restrictions and exclusions vary by coverage and state. Read your 
certificates and/or policies carefully for full details. If you have other insurance that covers the same risks as described, you may not need or want to purchase this insurance. 
This credit insurance is optional. You are not required to purchase the insurance to obtain credit. You are free to cancel anytime. Premium rates are subject to change. Rates 
disclosed are accurate as of the printing date of this disclosure. The underwriters referenced below reserve the right to modify the terms and conditions of the insurance 
certificates and/or policies upon written notice and subject to state regulations. COVERAGE IS NOT AVAILABLE IN: FL, KY, MA, MN, NH & NY LIFE, DISABILITY, 
UNEMPLOYMENT AND LEAVE OF ABSENCE COVERAGES APPLY ONLY TO THE PERSON WHOSE NAME APPEARS FIRST ON THE ACCOUNT.  LIFE 
COVERAGE: If you die, Chargegard will pay to the Creditor the outstanding account balance as of the date of death, up to the master policy maximum of $10,000. Suicide is 
excluded except in MD & MO. Life coverage is replaced with Accidental Death coverage at age 66 in IA. Life is not available in TX.  DISABILITY: If you become totally 
disabled, Chargegard will pay to the Creditor your scheduled minimum monthly payment due on your account on the date of loss. Benefits begin after 30 consecutive days of 
disability and are retroactive to the first day of loss. Benefits will continue until your balance on the date of loss is paid off, you return to work, you are no longer disabled, or 
you reach the master policy maximum of $10,000, whichever occurs first. In GA and SD you are eligible for coverage if employed full-time in a nonseasonal occupation. 
Disability benefits are not payable for self-inflicted injury (except in AL, GA, IA, MD & SD); flight in nonscheduled aircraft in PA; normal pregnancy in CA & PA. Disability is not 
available in TX. UNEMPLOYMENT COVERAGE: If you become involuntarily unemployed, Chargegard will pay to the Creditor your scheduled minimum monthly payment 
due on your account as of the date of loss, until your balance is paid off, you return to work, or you reach the $10,000 master policy maximum, whichever occurs first. In TX 
you are eligible for coverage if you are employed for 90 days at least 30 hours a week in a nonseasonal occupation for the same employer, and are not self employed, an 
independent contractor or a controlling stockholder of your employer; in IA & GA if employed full-time in a nonseasonal occupation; in PA if working 30 or more hours per 
week for at least 9 months of the year. Benefits begin after 30 consecutive days of unemployment and are retroactive to the first day of loss. Unemployment benefits are 
limited to 12 months in PA. Unemployment excludes discharge for cause (except in AL, AZ, GA, IA, PA, SC & SD); willful or criminal misconduct in AZ, CO, MD, MO & TX; 
forbidden acts, violation of established policies or neglect of duty in MO & TX; being notiified either orally or in writing of pending unemployment in TX; normal seasonal 
unemployment in TX. Unemployment coverage is not available in ND & NE.  LEAVE OF ABSENCE: If you take an employer-approved unpaid leave of absence from work 
due to: accident or illness of an immediate family member; childbirth / adoption; recall to active military service; residing in a federally-declared disaster area; placement of a 
foster child in your home (in NC only); or petit or grand jury duty (in NC only), Chargegard will pay to the Creditor your scheduled minimum monthly payment based on the 
outstanding balance as of the date of leave until your balance is paid off, you return to work, or you reach the $10,000 master policy maximum, whichever occurs first. 
Benefits begin after 30 consecutive days of leave and are retroactive to the first day of leave. In AL, CO, GA, IA, MD, PA & SD, you are eligible for this coverage if employed 
full-time, in a non-seasonal occupation and are not selfemployed. Benefit payments do not apply to leave during the first 90 days of coverage (except in CA, KS, MD, ND & 
OR). Leave of absence benefits are limited to 9 months in OR; 18 months in MD. Leave of Absence coverage is not available in MO, TX & VA.  GENERAL PROVISIONS: 
Maximum enrollment age in all states is 70, except 65 in CO, IA, & PA; 69 in AL, AZ, GA & SD; 71 in NM. No maximum enrollment age in TX. Coverage terminates in all 
states at age 71, except 66 in CO & PA; 70 in AZ; 72 in NM. No termination age in AL, IA, GA, SD & TX. COST PER $100 PER MONTH: 70.6¢ in AK; 76.7¢ in AL; 91.4¢ in 
AR; 71.1¢ in AZ; 85¢ in CA; 47.6¢ in CO; 83.8¢ in CT; 85.7¢ in DC; 89¢ in DE; 79.8¢ in GA; 72.5¢ in HI; 86.4¢ in ID; 73.7¢ in IA; 82.9¢ in IL; 70.9¢ in IN; 85.6¢ in KS; 96.4¢ 
in LA; 65.9¢ in ME; 41.9¢ in MD; 82.3¢ in MI; 53¢ in MO; $1.068 in MS; 81¢ in MT; 70.4¢ in NJ; 70.3¢ in NM; 87.9¢ in NV; 56.8¢ in NC; 44.9¢ in ND; 46.2¢ in NE; 73.8¢ in 
OH, 86.1¢ in OK; 71.9¢ in OR; 65.6¢ in PA; 77.9¢ in RI; 82.2¢ in SC; 82¢ in SD; 88.2¢ in TN; 19¢ in TX; 80.1¢ in UT; 34.3¢ in VA; 63.6¢ in VT; 68.4¢ in WI; 89¢ in WV; 75.4¢ 
in WA; 86¢ in WY. The cost of credit insurance will be financed at the rate specified in your agreement with the creditor. Coverage is underwritten by American Bankers Life 
Assurance Company of Florida, American Bankers Insurance Company of Florida and American Reliable Insurance Company, 11222 Quail Roost Drive, Miami, FL 33157-
6596. In TX unemployment certificate number – AD9139CQ-0499. In CA, life and disability coverage provided by ABLAC and ARIC provides remaining coverages described 
above. Coverage for life and disability is provided under form numbers AE2415PL-0999, B3539PQ-0397, AR8758EQ-0297 & AR8770EQ-0597. The creditor has a financial 
interest in the sale of this insurance. Ana Aguila is the licensed agent for the states of ND & WV. Coverages are only available as a package. If you cancel within 30 days of 
receiving your certificate, we will refund your premium. Insurance and cost disclosures are accurate as of the printing date. This insurance product is not a deposit, nor is 
it insured or guaranteed by the FDIC, First State Bank, or any Federal Government Agency. We may not condition your extension of credit on either: your 
purchase of an insurance product from us or our affiliates, your agreement not to obtain insurance from an unaffiliated entity, or a prohibition on your obtaining 
insurance from an unaffiliated entity. AR, LA, ME, NM, OH, TN & VA residents: Any person who knowingly and with intent to defraud any insurance company or other 
person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning 
any fact material thereto, commits a fraudulent insurance act, which is a crime and may subject such person to criminal and substantial civil penalties. (VA residents; this 
notice is not applicable to life and health insurance). DC residents: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the 
insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim 
was provided by the applicant. NJ residents: Any person who includes false or misleading information on an application for insurance policy is subject to criminal and civil 
penalties. PA residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 
containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, 
which is a crime and subjects such person to criminal and civil penalties. WA residents: It is a crime to knowingly provide false, incomplete, or misleading information to an 
insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.  

 YES. Please enroll me in the optional CHARGEGARD program as described above. 

X 

Applicant Signature 

Birthday 
(MM/DD/YY) 
Date: