Assurity Declined Life – OCi Services

Assurity E-Application Form

Death and Dismemberment- Assurity form

Thank you for your interest in writing business with Assurity Life Insurance Company

Which upline Agency are you associated with:(Required)

American Family

Shelter Insurance

Farm Bureau Financial Services

Missouri Farm Bureau

Michigan Farm Bureau

Modern Woodman

Farmer's

Proposed Insured Information

Name(Required)

First Middle Last

Date of Birth(Required)

Age(Required)

Social Security Number:(Required)

Please list full SSN

Gender:(Required)

Male

Female

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Phone Number:(Required)

Birth State and Country(Required)

State / Province / Region Country

Is the Proposed Insured a United States citizens, or does the Proposed Insured have permanent resident status?(Required)

Yes

Policy Owner

If the Policy Owner is the same as the Proposed Insured, you do not need to complete the attached section

Is the Proposed Insured the same as the Policy Owner? If Yes, you do not need to complete the section below.(Required)

Yes

Name(Required)

First Middle Last

Date of Birth(Required)

Social Security Number:(Required)

Please list full SSN

Relationship to Insured:(Required)

Email(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Birth State & Country(Required)

State / Province / Region Country

Beneficiaries

Primary Beneficiary Name(Required)

First Middle Last

Relationship(Required)

Social Security Number:(Required)

Please list full SSN

Date of Birth(Required)

Share Percentage (number only):(Required)

Primary Beneficiary Name

First Middle Last

Relationship

Social Security Number:

Please list full SSN

Date of Birth

Share Percentage (number only):

Contingent Beneficiary Name:

First Middle Last

Relationship:

Social Security Number:

Please list full SSN

Date of Birth

Share Percentage (Number only):

Contingent Beneficiary Name:

First Middle Last

Relationship:

Social Security Number:

Please list full SSN

Date of Birth

Share Percentage (Number only):

Other Insurance Information

Does the Proposed Insured have any other insurance coverage in force? If YES, please provide details below:(Required)

Yes

Insurance Company Name:(Required)

Life Insurance Amount:(Required)

Disability Insurance Amount:(Required)

Being Replaced?

Yes

Insurance Company Name:

Life Insurance Amount:

Disability Insurance Amount:

Being Replaced?

Yes

If this insurance is issued, will it replace, modify or borrow against existing or pending?(Required)

Yes

Accidental Death and Dismemberment Product Information

Benefit Amount:(Required)

Premium Amount Quoted:(Required)

Coverage Period (Select desired Coverage Period)(Required)

Guaranteed Renewable to age 80

5 year

7 year

10 year

15 year

20 year

30 year

Optional Benefit(s)

Check Benefit(s) desired and indicate the amount requested where applicable(Required)

Accident Only Disability Income Rider Benefit (Monthly Benefit Amount, Complete Section below- Employer Information)

Child Accidental Death and Dismemberment Rider (Benefit Amount, Complete Section Below- Spouse & Child Rider Information)

Critical Accident Rider

Disability Waiver of Premium Rider (Complete section below, Employer Information)

Return of Premium Rider (Only available for Guaranteed Renewable to age 80, 20 & 30 year coverage periods)

Spouse Accidental Death and Dismemberment Rider (Benefit Amount, Complete Section below- Spouse & Child Rider Information)

None of the above

Monthly Benefit Amount: (Complete section below, Employer Information)(Required)

Benefit Amount (Complete section below, Spouse and Child Rider Information)(Required)

If you selected Spouse Accidental Death and Dismemberment Rider, other benefits available are:

Critical Accident Rider

None of the Above

Employer Information

Is the Proposed Insured currently working at least 30 hours per week in primary occupation:(Required)

Yes

Primary Employer Company Name(Required)

Occupation:(Required)

Duties:(Required)

Gross Monthly Income:(Required)

Length of Employment: (Years/Months)(Required)

Spouse & Child Rider Information

Complete first section for spouse and the following section for each child on the rider.

Spouse Name(Required)

First Middle Last

Spouse's Date of Birth(Required)

Spouse's Age(Required)

Spouse's Social Security Number:(Required)

Please list full SSN

Spouse's Birth State and Country(Required)

State / Province / Region Country

Spouse's Gender(Required)

Male

Female

Residing with Proposed Insured?(Required)

Yes

Spouse's Email(Required)

Child Number 1 Name:(Required)

First Middle Last

Child Number 1 Date of Birth:(Required)

Child Number 1 Age:(Required)

Child Number 1 Social Security Number:(Required)

Please list full SSN

Child Number 1 Birth State and Country(Required)

State / Province / Region Country

Child Number 1 Gender(Required)

Male

Female

Child Number 1 Residing with Proposed Insured:(Required)

Yes

Child Number 1 Email (if applicable)

Child Number 2 Name:

First Middle Last

Child Number 2 Date of Birth:

Child Number 2 Age:

Child Number 2 Social Security Number:

Please list full SSN

Child Number 2 Birth State and Country

State / Province / Region Country

Child Number 2 Gender

Male

Female

Child Number 2 Residing with Proposed Insured:

Yes

Child Number 3 Name:

First Last

Child Number 3 Date of Birth:

Child Number 3 Age:

Child Number 3 Social Security Number:

Child Number 3 Birth State and Country

State / Province / Region Country

Child Number 3 Gender

Male

Female

Child Number 3 Residing with Proposed Insured:

Yes

Agent's Information

Agent Name:(Required)

First Last

Agent Phone Number:(Required)

Agent Email:(Required)

American Family Agent Number:(Required)

Premium Payment Information- Please indicate preference for payment type and billing frequency below:

Payor Name(Required)

First Middle Last

Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Payment Information

Day of withdrawal (cannot be the 29th, 30th, or 31st. If no day is entered, the policy issue date will be used. Assurity will begin processing your bank draft on the day selected. Due to bank's processing time, the actual day a withdrawal is posted to your account could be two or more days after the day selected.)(Required)

Please enter a number from 1 to 28.

Frequency (If no option is selected, Monthly will be applied):(Required)

Monthly

Quarterly

Semi-Annual

Annual

Financial Institution Name(Required)

Routing Number(Required)

Account Number(Required)

Payment Option(Required)

Credit/Debit Card

Bank Account

Credit/Debit Card Number:(Required)

Expiration Date: (MM/YY)(Required)

CVV:(Required)

Financial Institution Name(Required)

Routing Number(Required)

Account Number(Required)

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