Corebridge E-App Test

Disclaimer*

Please be advised, OCI is the Agent of Record on file with the Carrier, Corebridge, for this policy. If the policy owner need to make any changes to the policy, they will need to contact the Customer Service Department of Corebridge. Customer Service contact information as well as online service account instructions will be provided within the policy. Only the policy owner and Agent of Record have the ability to services accounts. Examples of changes include: bank changes, beneficiary changes, etc. By checking the box you acknowledge this statement and agree to the above.

Agent Information

Which upline Agency are you associated with:*

American Family
Shelter Insurance
Farmers
Missouri Farm Bureau
Michigan Farm Bureau
Farm Bureau Financial Solutions
Modern Woodman

Agent Name*

First Last

Agent Phone Number*

Agent Email:*

American Family Agent Number:*

Farm Bureau Financial Services Agent Number:*

Date of Birth:*

Business Address:*

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

License Information

National Producer Number:*

Applicant Information (Proposed Insured)

Applicant Name:*

First Last

Date of Birth*

Place of Birth State:*

State / Province / Region

Place of Birth Country:*

Country

Social Security Number*

Gender*

Address*

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

Phone*

Mobile Phone (if different from above)

Applicant Email:*

Do you have any existing annuity or life insurance or have any application pending for such coverage with this Company or any other company?*

Yes
No

Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract?*

Yes
No

You have mentioned that the Primary Insured is considering replacement, you will not be able to proceed with this application.

Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract?

Yes
No

You have mentioned that the Primary Insured is considering replacement, you will not be able to proceed with this application.

Will the life insurance policy being applied for replace or change any annuity or life insurance coverage in force or pending?

Yes
No

You have mentioned that the Primary Insured would replace or change any annuity or life insurance coverage in force or pending with the life insurance policy being applied for. You will not be able to proceed with the application.

Are you a United States Citizen or do you have Permanent Legal Resident (Green Card) status?

Yes
No

You have mentioned that the Primary Insured is not a US Citizen. You will not be able to proceed with the application.

Policy Information

Coverage Amount:*

Premium Amount Quoted ($):*

Payment Frequency:*

Monthly
Quarterly
Semi-Annually
Annually

Beneficiary Information

Beneficiary Name*

First Last

Relationship to Insured:*

Percent Allocated:*

Do you need to add additional beneficiaries?*

Yes
No

Second Beneficiary Name:*

First Last

Relationship to Insured:*

Percent Allocated:*

Payor Information

Is Payor same as insured?*

Yes
No

Payor Name*

First Last

Email:*

Relationship to Insured:*

Date of Birth:*

Phone Number:*

Social Security Number:*

Home Address:*

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

Schedule your first and recurring payment

Please Note: Your policy is not active until your policy is submitted and the payment is received.

Select an Option:*

Effective upon Application Submission
Select a particular date
Select the week and weekday

Select a Specific Date:

Week

Weekday

Payment Information

Payment Option*

Bank Account
Credit Card

Financial Institution Name*

Routing Number*

Account Number*

Financial Institution Name:*

Routing Number:*

Account Number:*

Verify Account Number:*

Account Type:*

Checking
Savings

Credit Card Number:*

Card Type (American Express, Mastercard, Visa, etc.):*

Expiration Date:*

Card Billing Address:*

Use Insured Address
Add New Billing Address

New Billing Address:*

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

E-App Submission*

By checking this box I (both the owner and proposed insured agree: (1) I represent statements in this application are complete and true. (2) When the policy is delivered, the proposed insured must be alive and in the same health as described above or there will be no insurance. (3) No insurance exists unless and until coverage is approved by Corebridge Financial, the first premium is paid, and the policy is delivered.

Authorization

I, the proposed insured, authorize any physician, hospital, pharmacy, pharmacy benefit manager, health insurance plan or any other entity that possesses any diagnosis, treatment, prescription or other medical information about me to furnish such health information to Wellabe Insurance Company and the entities with which it contracts to administer insurance application (collectively OCI) and their agents and representatives for the purpose of evaluating my eligibility for insurance. This medical or health information may include information on the diagnosis and treatment of mental illness, alcohol, and drug use. This also includes information on diagnosis, treatment, and testing results related to HIV, AIDS, and sexually transmitted diseases, unless otherwise restricted by state law. This authorization overrides any restrictions that I may have in place with any entity regarding the release of my medical information. Health information obtained will not be re-disclosed without my authorization unless permitted by law, in which case it may not be protected under federal privacy rules. This authorization shall be valid for two years from this date and may be revoked by sending written notice to the OCI. Non-health information is all other information. It may be about employment, other insurance owned, or motor vehicle, consumer or credit reports. It may also be information used to confirm questions and answers on the application for insurance. I authorize disclosure of this information to the OCI by any of the following sources: doctors, medical Practitioners, hospitals, clinics, or other medical or medically related facilities or professionals; the OCI's legal representatives or agents; insurers or reinsurers; health plans; consumer reporting agencies; public records; employers; Pharmacy Benefit Manager (PBM); or the Medical Information Bureau (MIB). I authorize OCI or its reinsurers to make a brief report of my personal health information to the MIB. I affirm that no illustration was used in the sale of this product. I understand: I can refuse to sign this Authorization. If I refuse, OCI will not be able to consider my application(s). I can revoke this Authorization at any time, except to the extent that OCI has acted in reliance upon it or other law that gives OCI the right to contest a claim under the policy or the policy itself. Revoking this Authorization mean that OCI will not be able to consider my application(s). Requests to revoke must be in writing and sent to Corebridge Financial. Subject to state and federal laws, information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient and may no longer be protected. I(or my authorized personal representative) am entitled to and will be sent a copy of this Authorization. This, Authorization expires in 24 months from the date I sign it. This time limit complies with the time limit, if any, permitted by applicable law in the state where the policy is delivered or issued for delivery. I may request to be interviewed in connection with the preparation of a consumer report and, upon written request, receive a copy of the report. I agree that a copy of this Authorization is as valid as the original. FRAUD WARNING: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

Agent Certification

I certify that the answers from the proposed insured to Medical Information were recorded accurately.

Agent Full Name*

First Last

Date*

CAPTCHA

Corebridge E-Application

Agent Information

License Information

Applicant Information (Proposed Insured)

Policy Information

Beneficiary Information

Payor Information

Schedule your first and recurring payment

Payment Information

Authorization

Agent Certification