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Group Disability
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Declined Life Cases

Declined Life Cases > Guaranteed Issue Options

Accidental Death E-Application

If this is a business case, please notify OCI prior to submitting as there may be additional forms needed.

Agent Information
Agent Name:*
First Last
Agent Email:*
Agent Phone:*
Agent SSN:*
Please choose the OCI Sales Executive helping you with this case:*
Proposed Insured Information
First Name:*
Middle Initial:
Last Name:*
Gender:*
- Male
- Female
Phone:*
Email:*
Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Tobacco Use?*
- Yes
- No
Tobacco Use: What type?*
U.S. Citizen?*
- Yes
- No
Birth Date:*
MM slash DD slash YYYY
Birth State/Country:*
SSN:*
Do they have a driver's license?*
- Yes
- No
DL #:*
Expiration:*
MM slash DD slash YYYY
Employer:*
Occupation:*
Purpose of insurance:*
Bank Information
Financial Institution Name:*
Routing Number:*
Account Number:*
Requested Withdraw Date:*
MM slash DD slash YYYY
Proposed Accidental Death Insurance
Carrier:*
Face Amount:*
Premium:*
Premium Frequency:*
Other Options
Waiver of Premium Rider?
- Yes
- No
Is the proposed insured working at least 30 hours per week in primary occupation?*
- Yes
- No
Length of Employment:
Years*
Months*
Company Name, Occupation, and Duties*
If the proposed insured works less than 30 hours a week, you cannot select this premium rider or the Accident-Only Disability Income Benefit Rider. You can only select the Return of Premium Rider.
Accident-Only Disability Income Rider?*
- Yes
- No
Gross Monthly Income:*
Monthly Benefit Amount: (Dollar Amount Must Be a Minimum of $300.)*
Return of Premium Rider?*
- Yes
- No
Beneficiary Information
First Beneficiary Name:*
First Last
First Beneficiary Relationship:*
First Beneficiary %:*
Second Beneficiary Name:
First Last
Second Beneficiary Relationship:
Second Beneficiary %:
Replacement Questions
Clients have existing life insurance?*
- Yes
- No
Is this replacing another policy?*
- Yes
- No
Carrier:*
Policy #:*
Face Amount:*
Type of Plan:*
- Term
- Permanent
E-App Submission*
- By checking this box you are giving OCI permission to submit an e-app with you being listed as the agent of record.
CAPTCHA

If after clicking the submit button if you do not see your request has been submitted, a problem may have occurred so please contact lifesales@ociservices.com to make sure the e-app was received.

Questions? Please email lifesales@ociservices.com.

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