Declined Life Cases

Declined Life Cases > For Face Amount of $249,999 and Below

Great Western E-Application

Disclaimer*
Please be advised, OCI is the Agent of Record on file with the Carrier, Great Western, 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 Great Western. 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:*
MM slash DD slash YYYY
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*
MM slash DD slash YYYY
Gender*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Mobile Phone (if different from above)
Applicant Email:*
Have you used tobacco in any form, electronic cigarettes, or other nicotine products in the past 12 months?*
Owner (Complete only if other than proposed insured)
Will the Proposed Insured be the Owner?*
- No
- Yes
Name
First Last
Date of Birth*
MM slash DD slash YYYY
Gender*
- Male
- Female
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email Address:*
Relationship to Insured:*
Medical Information
For purposes of these questions, "you" means the proposed insured.
Are you currently or have you been advised in the past 3 months by a licensed member of the medical profession to be hospitalized, confined to a nursing facility, receiving home health care, or in hospice?*
- Yes
- No
Do you require assistance or supervision to perform routine daily activities such as bathing, dressing, eating, tolieting, or transferring to or from a bed or chair?*
- Yes
- No
Do you require use of an electric scooter or are confined to a wheelchair as advised by a licensed member of the medical profession due to chronic medical condition or illness?*
- Yes
- No
Do you require use of oxygen or oxygen equipment to assist with breathing?*
- Yes
- No
Do you currently have or are you being treated by a licensed member of the medical profession for any form of cancer(excluding basal cell skin cancer) or have been treated for a reoccurence of a previous cancer or metastatic cancer (cancer that has spread to other parts of the body)?*
- Yes
- No
In the past 24 months have you been diagnosed, treated, tested positive, given medical advice, recommended treatment or prescribed medication by a licensed member of the medical profession for:*
- Select All
- Alzheimer's disease, dementia, or organic brain disorder
- Terminal illness that is expected to result in death within the next 12 months
- Amyotrophic lateral sclerosis (ALS)
- Congestive Heart Failure or cardiomyopathy
- Amputation due to disease
- Sickle cell anemia
- Respiratory failure, cystic fibrosis, or pulmonary fibrosis
- Kidney failure, chronic kidney disease, or kidney dialysis
- Cirrhosis of the liver, liver failure, or any chronic liver disease
- Organ or bone marrow transplant
- Diabetes with complications or in combination with a prior diagnosis of: Stroke/TIA, heart disease or disorder neuropathy, kidney disease, any circulatory disease that affects the heart and/or blood vessels, diabetic coma, or insulin shock
- None of the Above
Were you diagnosed by a licensed member of the medical profession with diabetes prior to age 30?*
- Yes
- No
Have you ever been diagnosed by a member of the medical profession or tested positive for Human Immunodeficiency Virus (AIDS virus) or Acquired Immune Deficiency Syndrome (AIDS).*
- Yes
- No
Within the past 12 months have you had any treatment, diagnostic testing, surgery, or hospitalization recommended by a medical professional which have not been completed or for which the results have not been received?*
- Yes
- No
Within the past 12 months have you had any unexplained weight gain or loss greater than 10 pounds?*
- Yes
- No
If any of questions 1 through 10 are answered "Yes" the proposed insured should apply for the Guaranteed Assurance Plan
In the past 36 months have you been diagnosed, treated, tested positive, given medical advice, recommended to have treatment, or prescribed medication by a licensed member of the medical profession for:
- Neuromuscular disease, Parkinson's disease, or multiple sclerosis
- Internal cancer (excluding basal cell skin cancers), malignant melanoma, leukemia, hodgkin's disease, myeloma, or lymphoma
- None of the Above
In the past 24 months have you been diagnosed, treated, tested positive, given medical advice, recommended to have treatment, or prescribed medication by a licensed member of the medical profession for:
- Select All
- Angina
- Systemic Lupus
- Drug or alcohol abuse, dependency, or addiction, illegal drug use or misused prescription drugs
- Hepatitis B, C, or Chronic hepatitis
- Chronic pulmonary disease, emphysema, chronic obstructive pulmonary disease (COPD), or chronic bronchitis or required the use of oxygen or oxygen equipment
- None of the Above
In the past 24 months have you been diagnosed, treated, tested positive, given medical advice, recommended to have treatment, or prescribed medication by a licensed member of the medical profession for:*
- Select All
- Heart Attack
- Embolism or blood clot
- Stroke or TIA (mini stroke)
- Irregular heart rhythm
- Seizures
- Aneurysm
- Heart, brain, or circulatory surgery, including pacemaker or defibrillator, cardioversion, stent placement, bypass, angioplasty, ablation, valve replacement or repair
- None of the Above
If any of questions 1 through 10 are answered "Yes" the proposed insured should apply for the Guaranteed Assurance Plan
Primary Care Physician
Do you have a Primary Care Physician? If yes, please input the name and phone number below.*
- Yes
- No
Physician information required for Great Assurance and Graded Death Benefit products
Primary Care Physician Name:*
Primary Care Physician Phone Number:*
Policy Information
Please select one of the following:*
- Guaranteed Assurance
- Graded Benefit
- Great Assurance
Death Benefit Amount/Face Amount: (please pick one)*
Payment Frequency:*
- Monthly
- Quarterly
- Semi-Annually
- Annually
Requested Effective Date- Month:*
Requested Effective Date- Day:*
You are not able to choose 29th-31st
Optional benefit riders:
- Dependent Child/Grandchild Rider (will need to complete separate application)
- Accidental Death Rider (only available with Great Assurance Final Expense)
Child/Grandchild's First and Last name:*
First Last
Child/Grandchild's Date of Birth*
MM slash DD slash YYYY
Are you a member of the United States Military, Military reserve, or the National Guard?
- Yes
- No
Total Premium Amount ($):*
Adjustments to Coverage & Premiums
The plans available through this application are, in order of highest to lowest immediate coverage, Great Assurance Final Expense, Graded Death Benefit, and Guaranteed Assurance. The owner ("you") agrees that you are applying for the plan with the highest immediate benefit and rate class for which you are eligible, beginning with the plan selected above. Eligibility is based on information in this application or obtained by the Company (defined below) during the underwriting process. The plan or face amount approved may be less than what is selected above and not all riders are available on all plans. If you are not eligible for the plan or rate class selected above, then, based on your election below, the Company will either adjust the face amount to match the premium listed above or adjust the premium to match the face amount listed above, subject to the Company's current rates, rate classes, and plan rules. If necessary, the premium may increase or decrease from what is listed above to meet the issued plan's rules.
Please select one of the following:*
- Adjust the face amount to match the premium
- Adjust the premium to match the face amount
Payor Information
Is Payor same as insured?*
- Yes
- No
Name*
First Last
Home Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Payment Information
Are you paying with Credit Card or Bank Account? (please select one of the two options)*
- Credit Card
- Bank Account
Financial Institution Name:*
Routing Number:*
Account Number:*
Verify Account Number:*
Account Type:
- Checking
- Savings
Card Type:*
- Visa
- Mastercard
Credit Card Number:*
Expiration Date:*
CVV:*
Bill Date:*
MM slash DD slash YYYY
Beneficiary Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Percent Allocated:*
Relationship to Insured:*
Do you need to add additional beneficiaries?*
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Percent Allocated:
Relationship to Insured:
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Percent Allocated:
Relationship to Insured:
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Percent Allocated:
Relationship to Insured:
Replacement Information
Do you have any existing insurance policies or annuity contracts?*
- Yes
- No
Will the insurance applied for replace or change any insurance or annuity that is now or has recently been in force? If Yes...*
- Yes
- No
Why is the existing contract being replaced?*
Insurer Name:*
Insured or Annuitant Name:*
Contract or Policy Number:*
Are you considering using funds from your existing policies or contract to pay premiums due on the new policy or contract?*
- Yes
- No
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 healthas described above or there will be no insurace. (3) No insurance exists unless and until coverage is approved by Great Western Insurance Company, 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 Great Western 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: Great Western Insurance Company, P.O. Box 14410, Des Moines, Iowa 50306-3410. 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*
MM slash DD slash YYYY
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Declined Life Cases

Great Western E-Application

Great Western E-Application

Agent Information

License Information

Applicant Information (Proposed Insured)

Owner (Complete only if other than proposed insured)

Medical Information

If any of questions 1 through 10 are answered "Yes" the proposed insured should apply for the Guaranteed Assurance Plan

If any of questions 1 through 10 are answered "Yes" the proposed insured should apply for the Guaranteed Assurance Plan

Primary Care Physician

Policy Information

Adjustments to Coverage & Premiums

Payor Information

Payment Information

Beneficiary Information

Replacement Information

Authorization

Agent Certification