Life Application Part I
- ------- Use Dark Ink Only
PARAGON
LIFE INSURANCE COMPANY
100 South Brentwood
St. Louis, MO 63105
1. PROPOSED INSURED(S) 3. BENEFICIARY
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Proposed Insured (1) Primary Date of Birth Relationship % Share
First Name Initial Last Name JAMES DOE 01 / 01 / 89 SON 100
JOHN J. DOE
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Date of Birth State of Birth Sex Primary Date of Birth Relationship % Share
05 / 01 / 64 [X] Male [_] Female
/ /
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Social Security Number ------------------------------------------------------------
123 - 45 - 6789 -----------------------------------------------------------
Contingent Date of Birth Relationship % Share
Occupation Earned Income Net Worth
IRONWORKER / /
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Contingent Date of Birth Relationship % Share
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Proposed Insured (2) ------------------------------------------------------
First Name Initial Last Name
JANE A. DOE ------------------------------------------------------------
Date of Birth State of Birth Sex 4. HEALTH STATUS
04 / 01 / 64 [_] Male [X] Female ------------------------------------------------------------
a. Have you been hospitalized within the previous 90 days?
Social Security Number Proposed Insured (1) [ ] Yes [X] No
234 - 56 - 7890 Proposed Insured (2) [ ] Yes [X] No
Occupation Earned Income Net Worth b. Have you used tobacco in any form within the last 24
months?
- --------------------------------------------------------------- Proposed Insured (I) [ ] No
[X] Yes Type: Amount/Frequency: Date Last Used:
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Home Address (Number, Street and Apt. #) CIGARETTES 1 PACK PER DAY
123 MAIN STREET ---------------------------------------------------------
Proposed Insured (2) [_] No
City State Zip [X] Yes Type: Amount/Frequency: Date Last Used:
ST. LOUIS, NO 11111
ST. LOUIS, MO 11111 CIGARETTES 1 PACK PER DAY
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2. REPLACEMENT 5. OWNER
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Will the insurance being applied for replace or Owner's First Name Initial Last Name
change any existing life insurance or annuity? [_] Yes [X] No
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--------------------------------------------------------------- Owner's Relationship to Proposed Insured
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Will the insurance being applied for receive any Owner's Address (Number, Street and Apt. #)
values (to pay premiums/additional payments)
from another policy/contract? [_] Yes [X] No -------------------------------------------------------
- ---------------------------------------------------------------- City/State Zip Telephone Number
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Owner's Social Security Number or Tax ID Number
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6. PLAN, BENEFITS & RIDERS
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Plan Name Desired Policy Date Benefit Riders (If available on plan selected)
FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE [X] Anniversary Partial Withdrawal Rider
- -------------------------------------------------------------- [X] Estate Preservation Term Rider
[X] Lifetime Coverage Rider
Face Amount Proposed Effective Date [X] Secondary Guarantee Rider
$100,000 [_] Other________________________
- -------------------------------------------------------------- [_] Other________________________
[_] Other________________________
Method of Payment (check one) and Premium
[_] One Payment $
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[X] Annual $ 974.37 /year
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[_] Semi-Annual $ /every six months
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[_] Monthly* $ /month
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*(Available only through automatic bankdraft which requires authorization)
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Policy Option: [X] Option A [_] Option B [_] Option C
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UNDERWRITING CONTACT INFORMATION
PROPOSED INSURED (1) PROPOSED INSURED (2)
Contact at: [X] Home (111)111-1111 Contact at: [X] Home (111) 111--1111
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(Phone Number) (Phone Number)
[_] Business [_] [Business
---------------------- --------------------
(Phone Number) (Phone Number)
Best days and time WED. 6:00 P.M. Best days and time WED. 6:00 P.M.
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Special Remarks Special Remarks
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[Additional Instructions/Home Office Endorsement (Not applicable in Kentucky, Maryland, Minnesota, Missouri, New Hampshire,
Pennsylvania, West Virginia, Wisconsin)]
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7. [ELECTRONIC PROSPECTUS OPTION
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In the future, Paragon Life Insurance Company may deliver prospectus updates, semi-annual and annual reports to consenting policy
owners electronically by the delivery methods listed below. If you wish to receive future updates in this manner, check your
choice below.
[_] 1) mailing a diskette containing the document;
[_] 2) mailing a CD-ROM containing the document;
[_] 3) e-mailing the document; or
[_] 4) e-mailing a notice identifying an Internet site where the document
can be viewed and downloaded.
Whichever option you choose, Paragon Life Insurance Company will supply the documents in a format compatible with one of the
following (please choose one):
[_] Microsoft Windows
[_] Macintosh
Please indicate your consent by checking the appropriate boxes.
You may incur normal and customary online usage charges to receive a document under Option 3 or 4. If you would like to receive
these documents in electronic format when available, please check the box and insert your e-mail address here
(____________________________). This consent will be in effect until you revoke it. You can revoke your consent by calling
Paragon Life Insurance Company's Service Center at: [1-800-638-9294] or writing to P.O. Box [14490], St. Louis, MO 63178. You may
revoke it at any time. If you consent to electronic delivery, at any time you also may request that we send you a paper copy.]
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8. VARIABLE LIFE INFORMATION
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1. Suitability Information:
a. Have you received the Paragon prospectus for the policy applied for? [X] Yes [_] No
Date of Prospectus: ____/___/___
Date of any supplement: ____/___/___
b. Have you received a prospectus for the underlying funds of the policy
applied for? [X] Yes [_] No
c. Do you understand that:
(i) the death benefit and cash surrender value will increase or
decrease depending on investment experience, and
(ii) there is no guaranteed cash surrender value? [X] Yes [_] No
d. Do you believe that the policy applied for meets your insurance
objectives and your anticipated financial needs? [X] Yes [_] No
2. Net Premium Allocation (Percentages must be in whole numbers, minimum of 5%
and total 100%); Default is 100% Money Market Portfolio:
SEPARATE ACCOUNT DIVISIONS:
[Fidelity - Contrafund Portfolio]......................................... 25 %
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[Fidelity - Equity-Income Portfolio]...................................... %
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[Fidelity - Growth Portfolio]............................................. %
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[Fidelity - Index 500 Portfolio].......................................... %
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[MFS - Emerging Growth]................................................... 25 %
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[Putnam - PVT High Yield Portfolio)....................................... %
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[Putnam - PVT New Opportunities Portfolio]................................ %
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[Putnam - PVT U.S. Government and High Quality Bond Portfolio]............ %
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[Putnam - PVT Voyager Portfolio).......................................... %
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[Scudder - International Portfolio]....................................... 25 %
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[Scudder - Money Market Portfolio]........................................ %
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[T. Rowe Price - Limited-Term Bond Portfolio]............................. %
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[T. Rowe Price - New America Growth Portfolio]............................ %
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[T. Rowe Price - Personal Strategy Balanced Portfolio].................... 25 %
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GENERAL ACCOUNT OPTION:........................................................... %
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DECLARATIONS
I agree that all the statements and answers in this application and any
amendments to it, including any supplements, are true, complete and correctly
recorded. I also agree that this application, any required medical examination,
and any supplement or amendment to either will be part of the policy, issued. If
a premium payment is given in exchange for a Temporary Insurance Agreement
(TIA), the Company will be liable only as set forth in that Agreement. If a
premium payment is not given, then insurance will take effect when a policy is
approved by the Company for issue as applied for, the first full premium is
paid, and the health and insurability of any person proposed for insurance have
not changed since the date of this application. If a policy is issued other than
as applied for, insurance will take effect under the policy only when a policy
issued by the Company is delivered to and accepted by me, the first full premium
is paid, and the health and insurability of any person proposed for insurance
have not changed since the date of this application.
PROPOSED INSURED'S AUTHORIZATION
I authorize any physician, medical practitioner, hospital, clinic, other medical
or medically related facility, insurance company, the Medical Information Bureau
(MIB), consumer reporting agency or employer to release to Paragon Life
Insurance Company its subsidiaries, its reinsurers or its legal representatives
any information they may have relative to diagnosis, treatment and prognosis of
any physical or mental condition including drug an or alcohol abuse and/or any
other information about me. I understand that any information obtained will be
used to determine eligibility for insurance and will not be released to any
person or organization except reinsurers, the MIB, other persons or
organizations performing business or legal services in connection with my
application, and other insurance companies to whom I have applied or to whom a
claim has been made, or as may be otherwise lawfully required, or as I may
further authorize. I know that I may request a copy of this authorization. I
also acknowledge receipt of the Notice of Information Practices. I understand
that if an investigative consumer report is ordered in connection with this
application, I may be interviewed in connection with the preparation of the
report and, upon request, I will be provided with a copy of the report. A
photographic copy of this authorization will be as valid as the original. This
authorization will be valid for 30 months from the date shown below.
OWNER'S CERTIFICATION: Under the penalties of perjury, I certify that: I) The
number shown on this form is my correct Taxpayer Identification Number (or, if
no number is shown, I am waiting for a number to be issued to me); and 2)I am
not subject to backup withholding either because I have not been notified by the
Internal Revenue Service (IRS) that I am subject to backup withholding as a
result of a failure to report all interest or dividends, or the IRS has notified
me that I am no longer subject to backup withholding.
PLEASE NOTE: Cross out and initial #2) above it you have been notified by the
IRS that you are currently subject to backup withholding because of
under-reporting interest or dividends on your tax return.
The IRS does not require consent to any provision of this document other than
the certifications required to avoid backup withholding.
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State where signed Date (MM/DD/YY) State where signed Date (MM/DD/YY)
X X
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Signature of Proposed Insured (1) Signature of Proposed Insured (2)
(Parent or Guardian if Proposed Insured under age 18) (Parent or Guardian if Proposed Insured under age 18)
X X
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Signature of Owner Signature of Owner
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AGENT:
Do you certify that you have truly and accurately recorded on this application
the information supplied by the applicant? [X] Yes [_] No
To the best of your knowledge, is this a replacement? [_] Yes [X] No
(If "Yes", complete and submit required replacement forms.)
X
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Signature of Licensed Agent Date (MM/DD/YY)
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[LOGO OF PARAGON LIFE INSURANCE COMPANY APPEARS HERE]
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Temporary Insurance Agreement and Advance Premium Receipt
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PLEASE READ CAREFULLY: This Agreement may provide a LIMITED AMOUNT of Life
--------------------- --------------
Insurance for a LIMITED PERIOD OF TIME, subject to the terms below. NO AGENT
----------------------
OR BROKER IS AUTHORIZED TO WAIVE OR CHANGE ANY OF THE TERMS OF THIS
AGREEMENT. ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO THE COMPANY. DO NOT
MAKE CHECK PAYABLE TO THE AGENT OR BROKER OR LEAVE THE PAYEE BLANK.
This Agreement must be completed when (and only when) money is paid in
conjunction with this agreement. Money cannot be accepted and no Temporary
Insurance will be in effect if the answer to any of the Health Questions
listed below is "Yes" or left blank.
We acknowledge receipt from John J. Doe a premium of $ 974.37 and an
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application numbered 123456 on which John J. and Jane A. Doe is (are)
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shown as the Proposed Insured(s). If the name(s) of the Proposed Insured(s)
shown on this Agreement and as shown in the application are not the same, NO
TEMPORARY INSURANCE will be in effect, even if money is paid.
Since variable life insurance coverage is being applied for, the date of the
check, the date the application was signed and the date this Agreement was
signed MUST be the same.
NOTE: To obtain the maximum period of coverage (60 days), at least 1/6th
of the annual premium must be submitted with this Agreement. If the
amount paid is less than 1/6th of the annual premium, the maximum
period of coverage will be proportionately less.
HEALTH QUESTIONS
NO MONEY SHOULD BE ACCEPTED IF ANY QUESTION BELOW IS ANSWERED "YES."
NO COVERAGE IS IN EFFECT UNTIL ALL REQUIREMENTS HAVE BEEN MET.
Has the Proposed Insured(s) or any person proposed for coverage in connection
with the application bearing the same number as shown above:
Proposed Proposed
Insured (1) Insured (2)
-----------------------------------
1. Within the past 90 days: Yes No Yes No
(a) been admitted to a hospital or other medical facility? [_] [X] [_] [X]
(b) been advised to be admitted to a hospital or other medical facility? [_] [X] [_] [X]
(c) had surgery performed or recommended? [_] [X] [_] [X]
2. Within the past 2 years, had or been treated for or been advised to be
treated for:
(a) heart disease, stroke, or cancer? [_] [X] [_] [X]
(b) alcohol or drug dependence or abuse? [_] [X] [_] [X]
By signing below, the Proposed Insured(s) states that he/she has received a
copy of and has read this Agreement including the terms and conditions on the
reverse side and declares that the answers to the Health Questions are true
to the best of his/her knowledge and belief. Also, the Proposed Insured(s)
and Applicant/Owner understand and agree to all of the terms of this
Agreement.
Signature of Proposed Insured (1)
Signed at (City, State) Date (Parent or Guardian if Proposed Insured under age 18)
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Signature of Proposed Insured (2)
Signed at (City, State) Date Parent or Guardian if Proposed Insured under age 18)
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Signature of Applicant/Owner
Witnessed by Licensed Agent (If other than Proposed Insured(s))
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Submit this original with the application.
This Form Can Only Be Used In
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Temporary Insurance Agreement and Advance Premium Receipt (Cont.)
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TERMS, CONDITIONS AND LIMITATIONS
AMOUNT OF COVERAGE: $500,000 Maximum for all Life Insurance Applications or
------------------
Agreements
Subject to the limitations contained in this Agreement, if money has been
accepted by the Company as advance payment for the Application for Life
Insurance identified by number in this Agreement, and if the Proposed
Insured(s) or any other person proposed for coverage dies while this
Agreement is in effect, the Company will pay to the Beneficiary named in that
application the LESSER of: (a) the amount of all death benefits applied for
on each such person, including any accidental or supplemental death benefits,
if applicable; or (b) $500,000. Even if more than one Temporary Insurance
Agreement and Advance Premium Receipt is in effect, the total amount paid
under all such agreements cannot be more than a maximum amount of $500,000.
This maximum amount also will be reduced by any other life and accidental
death insurance in force with us. The MINIMUM amount of temporary life
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insurance will be either the amount applied for or $50,000, whichever is
less.
DATE COVERAGE BEGINS: If an advance premium has been paid, Temporary
--------------------
Insurance under this Agreement will begin when the following requirements are
met:
1) This Agreement has been completed; and
2) The Application for Life Insurance and the Medical Declarations or
Application Part II have been fully completed; and
3) All required medical examination requirements have been completed.
DATE COVERAGE TERMINATES: Temporary Insurance under this Agreement will
------------------------
terminate automatically on the earliest of the following dates:
1) 60 days from the date of this Agreement; or
2) The date insurance begins under the policy(ies) applied for; or
3) The date a policy, other than applied for, is offered to the person
named as Owner in the application; or
4) The date the Company mails notice to the Proposed Insured(s) at the
address shown in the application that the application or this Agreement
has been declined by the Company.
SPECIAL LIMITATIONS:
-------------------
1) This Agreement provides benefits only for the type of insurance applied
for in the application. And, except as limited by this Agreement, our
liability is governed by the terms of the policy(ies) for which
application was made.
2) Fraud or misrepresentations in the application or in the answers to the
Health Questions in this Agreement invalidate this Agreement and the
Company's only liability is to refund any premium paid, plus interest.
3) If the Proposed Insured(s) dies by suicide, the Company's liability is
limited to a refund of any premium paid, plus interest.
4) There is no coverage under this Agreement if the check submitted with
the application is not honored by the bank the first time it is
presented.
5) No agent or broker is authorized to accept a payment for a Proposed
Insured(s) who is less than 15 days old or over age 70 on the date of
this Agreement.
Any payment made under this Agreement applies only to the purchase of
Temporary Insurance. If we issue the policy as applied for, or if you accept
a policy issued other than as applied for, then the amount paid will be
credited to the first year's premium due under the policy issued. Except as
otherwise provided under the terms of the policy, no refund will be made if
we issue a policy as applied for. The effective date of the policy issued
will be determined in accordance with our current policy dating procedures.
The full amount paid with this Agreement will be refunded to you, with
interest, if:
1) The application or this Agreement is declined or cancelled by us, or
2) We receive your signed request to cancel the application or this
Agreement.
Submit this original with the application.
This Form Can Only Be Used In
[LOGO OF PARAGON LIFE INSURANCE COMPANY APPEARS HERE]
- --------------------------------------------------------------------------------
Temporary Insurance Agreement and Advance Premium Receipt
- --------------------------------------------------------------------------------
PLEASE READ CAREFULLY: This Agreement may provide a LIMITED AMOUNT of Life
--------------------- --------------
Insurance for a LIMITED PERIOD OF TIME, subject to the terms below. NO AGENT
----------------------
OR BROKER IS AUTHORIZED TO WAIVE OR CHANGE ANY OF THE TERMS OF THIS
AGREEMENT. ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO THE COMPANY. DO NOT
MAKE CHECK PAYABLE TO THE AGENT OR BROKER OR LEAVE THE PAYEE BLANK.
This Agreement must be completed when (and only when) money is paid in
conjunction with this agreement. Money cannot be accepted and no Temporary
Insurance will be in effect if the answer to any of the Health Questions
listed below is "Yes" or left blank.
We acknowledge receipt from John J. Doe a premium of $ 974.37 and an
--------------- ------------
application numbered 123456 on which John J. and Jane A. Doe is (are)
---------- ---------------------------
shown as the Proposed Insured(s). If the name(s) of the Insured(s) shown on
this Agreement and as shown in the application are not the same, NO TEMPORARY
INSURANCE will be in effect, even if money is paid.
Since variable life insurance coverage is being applied for, the date of the
check, the date the application was signed and the date this Agreement was
signed MUST be the same.
NOTE: To obtain the maximum period of coverage (60 days), at least 1/6th
of the annual premium must be submitted with this Agreement. If the
amount paid is less than 1/6th of the annual premium, the maximum
period of coverage will be proportionately less.
HEALTH QUESTIONS
NO MONEY SHOULD BE ACCEPTED IF ANY QUESTION BELOW IS ANSWERED "YES."
NO COVERAGE IS IN EFFECT UNTIL ALL REQUIREMENTS HAVE BEEN MET.
Has the Proposed Insured(s) or any person proposed for coverage in connection
with the application bearing the same number as shown above:
Proposed Proposed
Insured (1) Insured (2)
---------------------------------
1. Within the past 90 days: Yes No Yes No
(a) been admitted to a hospital or other medical facility? [_] [X] [_] [X]
(b) been advised to be admitted to a hospital or other medical facility? [_] [X] [_] [X]
(c) had surgery performed or recommended? [_] [X] [_] [X]
2. Within the past 2 years, had or been treated for or been advised to be
treated for:
(a) heart disease, stroke, or cancer? [_] [X] [_] [X]
(b) alcohol or drug dependence or abuse? [_] [X] [_] [X]
By signing below, the Proposed Insured(s) states that he/she has received a
copy of and has read this Agreement including the terms and conditions on the
reverse side and declares that the answers to the Health Questions are true
to the best of his/her knowledge and belief. Also, the Proposed Insured(s)
and Applicant/Owner understand and agree to all of the terms of this
Agreement.
Signature of Proposed Insured (1)
Signed at (City, State) Date (Parent or Guardian if Proposed Insured under age 18)
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Signature of Proposed Insured (2)
Signed at (City, State) Date (Parent or Guardian if Proposed Insured under age 18)
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Signature of Applicant/Owner
Witnessed by Licensed Agent (If other than Proposed Insured(s))
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Proposed Insured(s)'s Copy
This Form Can Only Be Used In
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Temporary Insurance Agreement and Advance Premium Receipt (Cont.)
- --------------------------------------------------------------------------------
TERMS, CONDITIONS AND LIMITATIONS
AMOUNT OF COVERAGE: $500,000 Maximum for all Life Insurance Applications or
------------------
Agreements
Subject to the limitations contained in this Agreement, if money has been
accepted by the Company as advance payment for the Application for Life
Insurance identified by number in this Agreement, and if the Proposed
Insured(s) or any other person proposed for coverage dies while this
Agreement is in effect, the Company will pay to the Beneficiary named in that
application the LESSER of: (a) the amount of all death benefits applied for
on each such person, including any accidental or supplemental death benefits,
if applicable; or (b) $500,000. Even if more than one Temporary Insurance
Agreement and Advance Premium Receipt is in effect, the total amount paid
under all such agreements cannot be more than a maximum amount of $500,000.
This maximum amount also will be reduced by any other life and accidental
death insurance in force with us. The MINIMUM amount of temporary life
-------
insurance will be either the amount applied for or $50,000, whichever is
less.
DATE COVERAGE BEGINS: If an advance premium has been paid, Temporary
--------------------
Insurance under this Agreement will begin when the following requirements are
met:
1) This Agreement has been completed; and
2) The Application for Life Insurance and the Medical Declarations or
Application Part II have been fully completed; and
3) All required medical examination requirements have been completed.
DATE COVERAGE TERMINATES: Temporary Insurance under this Agreement will
------------------------
terminate automatically on the earliest of the following dates:
1) 60 days from the date of this Agreement; or
2) The date insurance begins under the policy(ies) applied for; or
3) The date a policy, other than applied for, is offered to the person
named as Owner in the application; or
4) The date the Company mails notice to the Proposed Insured(s) at the
address shown in the application that the application or this Agreement
has been declined by the Company.
SPECIAL LIMITATIONS:
-------------------
1) This Agreement provides benefits only for the type of insurance applied
for in the application. And, except as limited by this Agreement, our
liability is governed by the terms of the policy(ies) for which
application was made.
2) Fraud or misrepresentations in the application or in the answers to the
Health Questions in this Agreement invalidate this Agreement and the
Company's only liability is to refund any premium paid, p]us interest.
3) If the Proposed Insured(s) dies by suicide, the Company's liability is
limited to a refund of any premium paid, plus interest.
4) There is no coverage under this Agreement if the check submitted with
the application is not honored by the bank the first time it is
presented.
5) No agent or broker is authorized to accept a payment for a Proposed
Insured(s) who is less than 15 days old or over age 70 on the date of
this Agreement.
Any payment made under this Agreement applies only to the purchase of
Temporary Insurance. If we issue the policy as applied for, or if you accept
a policy issued other than as applied for, then the amount paid will be
credited to the first year's premium due under the policy issued. Except as
otherwise provided under the terms of the policy, no refund will be made if
we issue a policy as applied for. The effective date of the policy issued
will be determined in accordance with our current policy dating procedures.
The full amount paid with this Agreement will be refunded to you, with
interest, if:
1) The application or this Agreement is declined or cancelled by us, or
2) We receive your signed request to cancel the application or this
Agreement.
Proposed Insured(s)'s Copy
This Form Can Only Be Used In
[LOGO OF PARAGON LIFE INSURANCE COMPANY APPEARS HERE]
REQUEST FOR CONSIDERATION OF REINSTATEMENT
Request for consideration of reinstatement of policy number 16,000,001
--------------------
together with any supplemental agreements or riders, on the life/lives of
John Doe
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This policy lapsed for non-payment of the premium due January 1, 2000
--------------------------
TO THE PERSON/PERSONS INSURED BY THIS POLICY, PLEASE COMPLETE, SIGN BELOW and on
Page 2.
Please answer the following questions pertaining to all persons formerly covered
under this policy and any of its supplemental agreements or riders.
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INSURED #1
1. Are you in good health as of the current date? ................................... [_] Yes [_] No
2. In the past five years, have you had any accidents, disease, illness,
hospitalization or medical or surgical examination or treatments? ................ [_] Yes [_] No
If the answer is "No" to question #1 and/or "Yes" to question #2 above, please complete below:
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NAME OF INSURED
(If more space is needed, DETAILS OF DATES OF NAME AND ADDRESS OF
use other side.) ILLNESS OR INJURY TREATMENT RESULTS ATTENDING PHYSICIAN
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Dr. Smith, 300 Tree St
John Doe broken ankle 1-99 Good St. Louis, MO
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Date Signed City and State Signature of Insured #1
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OTHER INSUREDS
1. Are you in good health as of the current date? .................................. [_] Yes [_] No
2. In the past five years, have you had any accidents, disease, illness,
hospitalization or medical or surgical examination or treatments? ............... [_] Yes [_] No
If the answer is "No" to question #1 and/or "Yes" to question #2 above, please complete below:
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NAME OF INSURED
(If more space is needed, DETAILS OF DATES OF NAME AND ADDRESS OF
use other side.) ILLNESS OR INJURY TREATMENT RESULTS ATTENDING PHYSICIAN
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Date Signed City and State Signature of Other Insureds
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If address has changed, please provide new address for premium billings and other communications.
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CORPORATE OWNER, PLEASE COMPLETE: INDIVIDUAL OWNER(S), OTHER THAN INSURED,
- ----------------------------------------------------- PLEASE SiGN HERE:
Full name of corporation
x
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Signature and title of officer
x
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PLEASE READ AUTHORIZATION AND SIGN AT X ON BACK OF THIS FORM.
1
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AUTHORIZATION TO OBTAIN INFORMATION
I authorize any physician, medical practitioner, hospital, clinic, other
medical or medically related facility, insurance or reinsuring company, the
Medical Information Bureau, Inc., consumer reporting agency, or employer
having information available as to diagnosis, treatment and prognosis with
respect to any physical or mental condition and/or treatment of me or any
member of my family included in this policy and any other non-medical
information of me or any member of my family included in this policy to give
to Paragon Life Insurance Company or its legal representative, any and all
such information.
I understand the information obtained by use of the Authorization will be
used by Paragon Life Insurance Company to determine eligibility for
reinstatement of insurance and eligibility for benefits under an existing
policy. Any information obtained will not be released by Paragon Life
Insurance Company to any person or organization except to reinsuring
companies, the Medical Information Bureau, Inc., or other persons or
organizations performing business or legal services in connection with my
application, claim, or as may be otherwise lawfully required or as I may
further authorize.
I know that I may request to receive a copy of this Authorization. I agree
that a photographic copy of this Authorization will be as valid as the
original. I agree this Authorization will be valid for 30 months from the
date shown below.
For your protection the laws of several states require the following
statement:
Any person who knowingly and with intent to injure, defraud or deceive any
insurer or other person, files a statement of claim or an application
containing any materially false, incomplete or misleading information commits
a fraudulent insurance act, which is considered a crime in many states and
subjects such person to criminal and civil penalties. Penalties may include
imprisonment, fines, denial of insurance, and civil damages. In the state of
Florida such conduct makes a person guilty of a felony of the third degree.
Any insurance company or agent of an insurance company who knowingly provides
false, incomplete, or misleading facts or information to a policyholder or
claimant for the purpose of defrauding or attempting to defraud the
policyholder or claimant with regard to a settlement or award payable from
insurance proceeds will be reported to the state agency that regulates
insurance companies.
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Signature of Insured/Insureds
(if Insured is a minor, signature of parent or guardian)
x
--------------------------------------- -----------------------------
Date signed
x
--------------------------------------- -----------------------------
Date signed
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[LOGO OF PARAGON LIFE INSURANCE COMPANY APPEARS HERE]
2
AMENDMENT OF APPLICATION
------------------------
Policy Number: 16,000,001 Insured: John Doe
The application for this policy is amended as follows:
Proposed Insured's social security # is 123-45-6789.
This amendment and the application will be part of this policy.
Dated at
----------------------------- ----------------------------------
(Signature of Proposed Insured-
Parent of Guardian of Minor
Proposed Insured)
This day of year
------- ------- ----- ----------------------------------
(*Signature of Applicant/Owner)
- -------------------------------------- ----------------------------------
Signature of Additional Adult Insured
----------------------------------
*Signature and address if other
than Proposed Insured. If Owner
is a Corporation, Partnership,
or Trust, an authorized officer,
partner, or trustee must sign and
state title.
[LOGO OF PARAGON LIFE INSURANCE COMPANY APPEARS HERE]
PARAGON LIFE INSURANCE COMPANY
100 SOUTH BRENTWOOD
ST. LOUIS, MO 63105
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Home Office Use only: Face Amount PM Account # File #
- --------------------------------------------------------------------------------
APPLICATION PART II
1. Proposed Insured Birthdate Social Security Number
John J. Doe 5/1/64 123-45-6789
Premium Payer Billing Address
John J. Doe 123 Main Street, St. Louis. MO 11111
2. Employer's Name and Address Employer's Phone Number
Steam Iron Company 111-111-1122
3. Occupation Length of Employment Driver's License Number/State
Ironworker 15 years D123456789/MO
4. Are you a U.S. Citizen? Yes
[If no:
What country?
How long in U.S.A.?
Plan to remain?
Type of VISA?]
5. Do you plan to travel or reside outside the U.S.A. in the next two years? No
[If yes:
Travel or Reside?
Where?
When?
How long?
Purpose?]
6. Do you have other life insurance policies, including riders, in force? No
[If yes:
Name of company?
Face amount?
When issued?
Business or Personal?]
7. Will the insurance being applied for replace any of the policies listed in Question 6 above? No
[If yes:
Which company?
What amount?
Business or Personal?]
8. Have you, within the last 90 days, applied for life insurance with this or any
other company? No
[If yes:
What company?
Face amount?
Intend to accept?
Total amounts all companies to be accepted?]
PARAGON LIFE INSURANCE COMPANY
100 SOUTH BRENTWOOD
ST. LOUIS, MO 63105
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9. Have you ever been denied, rated, or offered a policy or rider other
than that applied for? No
[If yes:
What was the adverse action(s)?
Date(s) of action(s)?
Why was the action(s) taken (if known)?
Type of insurance?
Name of insurance company?]
10. Have you, within the past three years, had any moving vehicle violations? Yes
[If yes:
Type? Speeding
When? May 1996
Penalty?] Fine Paid
11. Have you, within the past ten years, had a traffic citation for driving while intoxicated
or driving under the influence of intoxicants or drugs? No
[If yes:
When?
Penalty?
Were classes required to reinstate license?
Treatment required?
Type of treatment? When? Where?]
12. a. Have you been a pilot or student pilot during the past three years or have any intention of
becoming a pilot in any type of aircraft within the next twelve months? No
[If yes:
Pilot license currently held?
Rating (s): Airline Transport Rating Instrument Flight Rating
Total solo hours flown as pilot?
Type and Schedule of hours flown as pilot, co-pilot, or other crew member:
- ---------------------------------------------------------------------------------------------
Type of Flying Type of Aircraft Date of Total to Last 12 Est. Next
Last Flight Date Months 12 Mos.
- ---------------------------------------------------------------------------------------------
Private?
- ---------------------------------------------------------------------------------------------
Student?
- ---------------------------------------------------------------------------------------------
Flight instructor?
- ---------------------------------------------------------------------------------------------
Commercial -
scheduled?
- ---------------------------------------------------------------------------------------------
Commercial -
Non-scheduled?
- ---------------------------------------------------------------------------------------------
Agriculture?
- ---------------------------------------------------------------------------------------------
Business?
- ---------------------------------------------------------------------------------------------
Civil Air Patrol?
- ---------------------------------------------------------------------------------------------
Military?
- ---------------------------------------------------------------------------------------------
Other?
(Give details)]
- ---------------------------------------------------------------------------------------------
PARAGON LIFE INSURANCE COMPANY
100 SOUTH BRENTWOOD
ST. LOUIS, MO 63105
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b. Have you flown during the past three years or intend to fly: ultralight, biplane,
prototype, experimental or personally built or assembled aircraft, or any other type
of aircraft, except as mentioned above? No
[If yes:
Type and Schedule of number of flights:
- --------------------------------------------------------------------------------------------------------
Type of Craft Club Usual Last 1-2 yrs Next Accident (if any)/Details
Member Location and 12 Ago 12
Details Type of Mos. Mos.
Terrain
- --------------------------------------------------------------------------------------------------------
Ultralight -
powered
- --------------------------------------------------------------------------------------------------------
Ultralight--
unpowered
- --------------------------------------------------------------------------------------------------------
Biplane?
- --------------------------------------------------------------------------------------------------------
Prototype?
- --------------------------------------------------------------------------------------------------------
Experimental?
- --------------------------------------------------------------------------------------------------------
Personally
built?
- --------------------------------------------------------------------------------------------------------
Personally
assembled?
- --------------------------------------------------------------------------------------------------------
Other?
(Give details)
- --------------------------------------------------------------------------------------------------------
Should you not qualify for coverage at standard rates, do you desire:
[ ] Full coverage with extra premium, if available?
[ ] Restricted aviation coverage without extra premium, if available?]
PARAGON LIFE INSURANCE COMPANY
100 SOUTH BRENTWOOD
ST. LOUIS, MO 63105
- --------------------------------------------------------------------------------
13. Have you participated within the past two years, or do you contemplate
participating in: Sky sports, motor vehicle racing, underwater diving,
mountain or rock climbing, or any other similar avocations? No
[If yes:
If Sky Sports:
Type and Schedule of number of flights or jumps:
- --------------------------------------------------------------------------------------------------------------------
Type Club Usual Last 1-2 Next Usual Greatest Accident (if any)/
member/ location 12 Yrs 12 height (in height/ Details
Certification and type Mos. Ago Mos. feet) distance
/Instruction of terrain (in feet)/
Duration
- ---------------------------------------------------------------------------------------------------------------------
Gas Ballooning?
- ---------------------------------------------------------------------------------------------------------------------
Hot air
ballooning?
- ---------------------------------------------------------------------------------------------------------------------
Hang gliding -
experimental
equipment with
parachute?
- ---------------------------------------------------------------------------------------------------------------------
Hang gliding -
experimental
equipment
without
parachute?
- ---------------------------------------------------------------------------------------------------------------------
Hang gliding
without
experimental
equipment with
parachute?
- ---------------------------------------------------------------------------------------------------------------------
Hang gliding
without
experimental
equipment without
parachute?
- ---------------------------------------------------------------------------------------------------------------------
Parachuting?
- ---------------------------------------------------------------------------------------------------------------------
Delayed
jumping
skydiving?
- ---------------------------------------------------------------------------------------------------------------------
Relative
freefall
skydiving?
- ---------------------------------------------------------------------------------------------------------------------
Relative canopy
skydiving?
- ---------------------------------------------------------------------------------------------------------------------
B.A.S.E.
jumping?
- ---------------------------------------------------------------------------------------------------------------------
Other?
(Give details)]
- ---------------------------------------------------------------------------------------------------------------------
PARAGON LIFE INSURANCE COMPANY
100 SOUTH BRENTWOOD
ST. LOUIS, MO 63105
- --------------------------------------------------------------------------------
[If Motor Vehicle Racing:
Type? Automobile Motorcycle Motorboat Snowmobile Other
Number of races:
Last twelve months?
1 to 2 Years Ago?
Next twelve months?
Type of race: Drag Stock Midget Sports Car Hot Rod Go Kart Other
Motorcycle Motorboat Snowmobile
Make?
Model?
Class?
Category?
Displacement?
Horsepower? Number of CC's?
Timing? Vehicle vs. Vehicle Vehicle vs. Clock
Maximum speed (mph)?
Average speed (mph)?
Distance of race?
Location? Oval track Closed Circuit Drag Strip Hill Climb
Other (Give details):
Type of road?
List all racing organization affiliations:
Races supervised by what organization(s)?
Ever or intend to compete outside U.S.A. or Canada?
If yes, Details:
Details of any racing accident:]
[If Motorboat:
Type(s) of event?
Type of boat?
Class and Category?
List all racing organization affiliations:
Races supervised by?
Average length?
Maximum speed?
Average speed?]
PARAGON LIFE INSURANCE COMPANY
100 SOUTH BRENTWOOD
ST. LOUIS, MO 63105
- --------------------------------------------------------------------------------
[If Underwater Diving:
When last certified?
Level of certification?
List all diving club affiliations:
Use buddy system?
Any night diving?
Number of Dives:
Depth Location Purpose Avg. Last 1 to 2 Next
i.e. Oceans, Lakes, i.e. time 12 years 12 Mos.
Cave, Ice, Recreation, Mos. ago
Other (details) Certification,
Rescue,
Salvage,
Other (details)
- ---------------------------------------------------------------------------------------------------------
0-100 ft
- ---------------------------------------------------------------------------------------------------------
101-150 ft
- ---------------------------------------------------------------------------------------------------------
Over 150 ft]
- ---------------------------------------------------------------------------------------------------------
[If Mountain or Rock Climbing:
Number of climbs:
Last 12 months?
1 to 2 years ago?
Next 12 months?
Type: Mountain Rock Ice Other (details):
Location: Ranges Caves Rock formations Trails Other (details):
Usual heights (ft)?
Maximum height (ft)?
How often climbed to maximum height?
Grade and Class (if known)?
Geographical area or specific ranges?
List all club affiliations:
Use direct-aid climbing?
Details of guide participation:
Details of rescue duty:
Details of any climbing accident:]
PARAGON LIFE INSURANCE COMPANY
100 SOUTH BRENTWOOD
ST. LOUIS, MO 63105
- --------------------------------------------------------------------------------
HEALTH STATEMENTS
14. a. Who is your personal doctor who can give us the most complete and up to
date information concerning your present health? Dr. Smith
(Indicate if "None")
b. [When was this doctor last consulted? March 1999 Why? Cold
What treatment was given or medication prescribed? None
Type of treatment? None
Types of medication prescribed? None Dosage? N/A
Doctor's address and Phone number:] 123 Elm Drive St. Louis, MO 11111
15. a. What is your height? 6'
b. What is your weight? 200lbs.
c. Any weight loss in the past year? No
[If yes,
Number of pounds lost?
Reason?]
16. Do you exercise? Yes
[If yes,
Type? Walk
How often?] Daily
17. Do you drink alcohol? Yes
[If yes,
Frequency? Weekends
How many drinks on average per occasion?] 2-4
18. a. Are your parents living?
Mother Yes Age 60 [Cause of Death, if deceased]
Father Yes Age 60 [Cause of Death, if deceased]
b. Have any brothers or sisters died of heart disease before
age 60? No
[If yes:
How many?
At what ages?]
19. In the last ten years have you had, been treated for, or
diagnosed as
having:
a. Cancer, disorder of the blood, stroke, or diabetes? Yes
[If yes,
If cancer:
When was the cancer diagnosed?
What type of cancer?
Where was the cancer?
What kind of treatment?
Currently taking medication?
If yes, Type(s)? Dosage?
Have all cancer studies been normal since end of treatment?
If no, Type(s) of study(ies)? Date of study(ies?) Results?
When was last visit to doctor?
What doctor has records? Name, Address, Phone Number]
PARAGON LIFE INSURANCE COMPANY
100 SOUTH BRENTWOOD
ST. LOUIS, MO 63105
- --------------------------------------------------------------------------------
[If disorder of the blood:
Name of blood disorder?
When diagnosed?
How treated?
How often?
Currently taking medication?
If yes, Type(s)? Dosage?
When was last visit to doctor?
What doctor has records? Name, Address, Phone number:]
[If stroke:
Dates of stroke(s):
What kind of permanent damage sustained?
Any reoccurrence of symptoms?
If yes, Describe symptoms? When did they occur? Have they resolved?
If yes, When?
Currently taking medication?
If yes, Type(s)? Dosage?
When was last visit to doctor?
What doctor has records? Name, Address, Phone number]
[If diabetes:
At what age was diabetes diagnosed? 30
Are you currently being treated with insulin for diabetes? No
If yes, Dosage? Times taken?
Any complications? No
If yes, What type(s)? When occurred?
Current medication (other than insulin)? Yes
If yes, Type(s)? Glyburide Dosage? 1 pill per day
Check blood sugar routinely? Yes
If yes, What does fasting level usually run? 115
When was last visit to doctor? February 1999
If within the last year, any blood tests? Yes
If yes, Type(s)? Glucose Results? Normal
What doctor has records? See #14 Name, Address, Phone number:]
b. High blood pressure, chest pain, heart attack, or any other disease or
disorder of the heart or circulatory system? No
[If yes,
If high blood pressure:
When first diagnosed?
Blood pressure reading taken within the last 3 months?
If yes, what was reading (if known)?
Any blood pressure reading over 140/90 within the last 2 years (if known)?
If yes, What were reading(s)? Approximate date(s) of reading(s)?
Any complications?
If yes, What type(s)?
Currently taking medication?
If yes, Type(s)? Dosage?
When was last visit to doctor?
What doctor has records? Name, Address, Phone number]
[If chest pain:
Dates of occurrence?
Has diagnosis been made?
How diagnosed?
Have symptoms remained stable?
If no: Describe symptoms:
Currently taking medications?
PARAGON LIFE INSURANCE COMPANY
100 SOUTH BRENTWOOD
ST. LOUIS, MO 63105
- --------------------------------------------------------------------------------
If yes: Type(s)? Dosage?
Currently involved in any form of cardiac rehabilitation?
If yes, What form(s)? Results?
Any tests done?
If yes, What type(s)? When? Results?
When was last visit to doctor?
What doctor has records? Name, Address, Phone number]
[If heart attack:
When was heart attack?
How treated?
Any chest pain or other heart symptoms since the heart attack?
If yes, When? How was it treated?
Currently taking medication?
If yes, Type(s)? Dosage?
Currently involved in any form of cardiac rehabilitation?
If yes, What type(s) How often?
Any tests done?
If yes, What type(s)? When? Results?
When was last visit to doctor?
What doctor has records? Name, Address, Phone Number]
[If other disease or disorder of the heart or circulatory system:
Name of condition?
When diagnosed?
How diagnosed?
How treated?
Currently taking medication?
If yes, Type(s)? Dosage?
When was last visit to doctor?
What doctor has records? Name, Address, Phone number:]
[If irregular heart beat:
When diagnosed?
How diagnosed?
When was last episode?
How often does this occur?
Currently taking medication?
If yes, Type(s)? Dosage?
Do you have a pacemaker?
If yes, When inserted?
When was last visit to doctor?
What doctor has records? Name, Address, Phone number:]
[If coronary artery disease:
When diagnosed?
How diagnosed?
Currently taking medication?
If yes, Type(s)? Dosage?
When was last visit to doctor?
What doctor has records? Name, Address, Phone number
Surgically treated?]
[If yes, What type of surgery?
If angioplasty:
When?
How many blockages opened?
Any heart attack before the angioplasty?
If yes, When? How treated?
PARAGON LIFE INSURANCE COMPANY
100 SOUTH BRENTWOOD
ST. LOUIS, MO 63105
- --------------------------------------------------------------------------------
Any chest pain since the angioplasty?
If yes, When? How treated?
Any follow up cardiac test(s) since the angioplasty?
If yes, What type(s)? Dates? Results?
Where done?
Currently involved in any cardiac rehabilitation?
If yes, What type(s)? How often?
Where is rehabilitation done?
Currently taking medication?
If yes, Type(s)? Dosage?
When was visit to doctor?
What doctor has records? Name, Address, Phone number]
[If bypass surgery:
When was surgery?
How many vessels bypassed?
Any heart attack before the surgery?
If yes, When?
Where was surgery done?
Any chest pain since the surgery?
If yes, When? How treated?
Any follow up cardiac test(s) since the surgery?
If yes, What type(s)? Dates? Results?
Where done?
Currently taking medication?
If yes, Type(s)? Dosage?
Currently involved in any form of cardiac rehabilitation
If yes, What type(s)? How often?
Where is rehabilitation done?
When was last visit to doctor?
Doctor who has records? Name, Address, Phone number]
[If other cardiac surgery:
What type(s) of surgery(ies) performed?
Dates of surgery(ies)?
Results?
Where performed?
Currently taking medication?
If yes, Type(s)? Dosage?
Any follow up cardiac tests since the surgery?
If yes, What type(s)? When? Result(s)?
When was visit to doctor?
Doctor who has records? Name, Address, Phone number]
[If heart murmur:
When discovered?
How discovered?
Description of murmur (if known):
Any symptoms?
If yes, Describe:
Currently taking medication?
If yes, Type(s)? Dosage?
Had echocardiogram within the last two years?
If yes, Date? Results?
When was last visit to doctor?
Doctor who has records? Name, Address, Phone number:]
PARAGON LIFE INSURANCE COMPANY
100 SOUTH BRENTWOOD
ST. LOUIS, MO 63105
- --------------------------------------------------------------------------------
c. Asthma, emphysema, or any other disease or disorder of the lungs or
respiratory system? No
[If yes,
If asthma:
When was last episode or attack?
How often do episodes occur?
How treated?
Currently taking medication?
If yes, Type(s)? Dosage?
Any hospitalizations or emergency room visits?
If yes, When? What hospital?
Hospital location?
When was last visit to doctor?
Doctor who has records? Name, Address, Phone number]
[If emphysema:
When diagnosed?
Any functional limitations as result of emphysema?
If yes, Describe:
Currently taking medication for emphysema?
If yes, Type(s)? Dosage?
Currently involved in any form of pulmonary rehabilitation?
If yes, Type(s)? How often?
Where is rehabilitation done?
When was last visit to doctor?
Doctor who has records? Name, Address, Phone number]
[If other disease or disorder of the lungs or respiratory system:
Name of the condition?
When diagnosed?
How treated?
Currently taking medication?
If yes, Type(s)? Dosage?
When was last visit to doctor?
Doctor who has records? Name, Address, Phone number]
d. Cirrhosis, hepatitis, or any other disease or disorder of
the liver? No
[If yes,
If cirrhosis:
When diagnosed?
How treated?
When was last visit to doctor?
Doctor who has records? Name, Address, Phone number]
[If hepatitis:
When diagnosed?
What type?
How diagnosed?
How treated?
Cured?
Currently taking medication?
If yes, Type(s)? Dosage?
When was last visit to doctor?
Doctor who has records? Name, Address, Phone number]
[If other disease or disorder of the liver:
Name of the liver disorder or disease?
When diagnosed?
How diagnosed?
PARAGON LIFE INSURANCE COMPANY
100 SOUTH BRENTWOOD
ST. LOUIS, MO 63105
- --------------------------------------------------------------------------------
How treated?
Currently taking medication?
If yes, Type(s)? Dosage?
When was last visit to doctor?
Doctor who has records? Name, Address, Phone number]
e. Any disease or disorder of the intestines, stomach, kidney,
bladder, or prostate? No
[If yes,
If intestines:
Name of the intestinal disorder or disease?
When diagnosed?
How treated?
When was last major flare-up?
How often are flare-ups?
Any bleeding episodes?
If yes, What dates? How treated?
Any surgery?
If yes, What type(s)? What date(s)? Where done?
Currently taking medication?
If yes, Type(s)? Dosage?
When was last visit to doctor?
Doctor who has records? Name, Address, Phone number]
[If stomach:
Name of the stomach disorder or disease?
When diagnosed?
How treated?
When was last major flare-up?
Any bleeding episodes?
If yes, What dates? How treated?
Any surgery?
If yes, What type(s)? What date(s)? Where done?
Currently taking medication?
If yes, Type(s)? Dosage?
When was last visit to doctor?
Doctor who has records? Name, Address, Phone number]
[If kidney:
Name of the kidney disorder or disease?
When diagnosed?
How discovered?
How treated? Date(s) of treatment?
Surgery?
If yes, What type(s)? What date(s)? Where done?
Currently taking medication?
If yes, Type(s)? Dosage?
When was last visit to doctor?
Doctor who has records? Name, Address, Phone number]
[If bladder:
Name of the bladder disorder or disease?
When diagnosed?
How discovered?
How treated? Dates of treatment?
Any surgery?
If yes, Type(s)? What date(s)? Where done?
Currently taking medication?
PARAGON LIFE INSURANCE COMPANY
100 SOUTH BRENTWOOD
ST. LOUIS, MO 63105
- --------------------------------------------------------------------------------
If yes, Type(s)? Dosage?
When was last visit to doctor?
Doctor who has records? Name, Address, Phone number]
[If prostate:
Name of the prostate disorder or disease?
When diagnosed?
How discovered?
When was last PSA level taken? Results?
How often is PSA level taken?
How treated? Dates of treatment?
Any surgery?
If yes, What type(s)? What date(s)?
Where done?
Currently taking medication?
If yes, Type(s)? Dosage?
When was last visit to doctor?
Doctor who has records? Name, Address, Phone number]
f. Depression, stress, anxiety, or any other psychological or
emotional disorder or symptoms? No
[If yes,
If depression, stress, anxiety:
When was initial diagnosis made?
How treated?
Ever hospitalized?
If yes, When? How long? How treated?
Type of follow up care? Frequency?
Currently taking medication?
If yes, Type(s)? Dosage?
When was last visit to doctor?
Doctor who has records? Name, Address, Phone number]
[If other psychological or emotional disorder or symptoms:
Name of disorder (if known)?
Describe symptoms:
When was initial diagnosis made?
How treated? What dates(s)?
Ever hospitalized?
If yes, When? How long? How treated?
Type of follow up care? Frequency?
Currently taking medication?
If yes, Type(s)? Dosage?
When was last visit to doctor?
Doctor who has records? Name, Address, Phone number]
20. a. In the last five years, have you consulted any other physician or other
medical practitioner? No
[If yes,
Reasons seen?
Dates seen?
How treated?
Results?
Any surgery performed?
If yes, Reason(s)? Date(s) of surgery?
Result(s)?
Who was the surgeon? Name, Address, Phone number
When was last visit to doctor?
Doctor who has records? Name, Address, Phone number]
PARAGON LIFE INSURANCE COMPANY
100 SOUTH BRENTWOOD
ST. LOUIS, MO 63105
- --------------------------------------------------------------------------------
b. Other than the above, during the past five years, have you had any
checkup, illness, injury, or health conditions, had or been
recommended to have any treatment, hospitalization, surgery, or
medical tests? Yes
[If yes,
If checkup:
Reason? Follow diabetes
Date? Last 5 years
What tests performed? Routine Bloodwork Results? Controlled
What doctor has records? See #14 Name, Address, Phone Number]
[If illness:
What was the illness?
What were the symptoms?
When?
Date of recovery?
Did you visit your doctor?
If yes, Doctor's Name, Address, Phone number]
[If injury:
When was the injury?
Extent of the injury?
Type of treatment? Results?
Date of recovery?
Currently taking medication?
If yes, Type(s)? Dosage?
When was last visit to doctor?
Doctor who has records? Name, Address, Phone number]
[If health condition:
Name of the condition?
Symptoms?
When diagnosed?
Type of treatment? Results?
Currently taking medication?
If yes, Type(s)? Dosage?
When was last visit to doctor?
Doctor who has records? Name, Address, Phone number]
[If treatment:
Type of treatment?
Name of the condition?
Date(s) of treatment? Results?
When was last visit to doctor?
Doctor who has records? Name, Address, Phone number]
[If hospitalization:
For what condition?
Dates of hospitalization(s)?
How long hospitalized?
Results?
Doctor/Hospital that has records? Name, Address, Phone number]
[If surgery:
For what condition?
Date of surgery(ies)? Results? Where done?
Date of recovery?
Doctor who has records? Name, Address, Phone number]
[If medical tests:
What type of test(s)?
PARAGON LIFE INSURANCE COMPANY
100 SOUTH BRENTWOOD
ST. LOUIS, MO 63105
- --------------------------------------------------------------------------------
Dates of test(s)?
Reason for test(s)? Results?
Doctor who has records? Name, Address, Phone number]
21. Have you ever:
a. Been diagnosed by a member of the medical profession as having AIDS
or AIDS Related Complex? No
[If yes,
What doctor or facility diagnosed? Name, Address, Phone number]
b. Tested positive for antibodies to the AIDS (HIV) virus? No
(If yes,
What doctor or facility diagnosed? Name, Address, Phone number]
22. Have you:
a. Used (once or more) or do you now use barbiturates, amphetamines,
hallucinogenic drugs (including marijuana), cocaine, heroin,
narcotics, any similar substances, or any prescription drug except in
accordance with a physician's instruction? No
[If yes,
Type of substance or drug?
What dates used?
Frequency of use?
Was any treatment recommended?
If yes, Type of treatment(s)? Date(s)?
Name of doctor or facility where treated? Name, Address, Phone number]
b. Been advised to limit or discontinue the use of alcohol or drugs;
sought or received treatment, counseling, or participated
in a group for alcohol or drug use? No
[If yes,
What type of advice given?
When was it given?
Did you comply?
What type of alcohol or drugs?
What was the frequency?
Date last used?
What type of treatment?
Dates of treatment(s)? Results?
What type of counseling?
Dates of counseling? Results?
What type(s) of group participation?
When did you start?
Why did you start?
How often was participation?
Are you still participating? Results?
Doctor or facility that has records? Name, Address, Phone number]
23. Other than the above, are you currently taking any medication, or have you
been advised to take any medication? No
[If yes,
If currently taking:
Type(s) of medication? Dosage?
Reason(s) why taken?
Doctor who has records? Name, Address, Phone number]
[If been advised:
Reason(s) why advised?
PARAGON LIFE INSURANCE COMPANY
100 SOUTH BRENTWOOD
ST. LOUIS, MO 63105
- --------------------------------------------------------------------------------
Type(s) of medication? Dosage?
Reason not yet taking medication?
Intended date of starting medication?
Doctor who has records? Name, Address, Phone number]
24. To the best of your knowledge, do you have any mental or physical
impairment or disease not already described in this application? No
[If yes,
If mental impairment or disease:
Type of mental impairment or disease?
When diagnosed?
How treated?
Dates of treatment? Results?
When was last visit to doctor?
What doctor has records? Name, Address, Phone number]
[If physical impairment or disease:
Type of physical impairment or disease?
When diagnosed?
How treated?
Dates of treatment? Results?
When was last visit to doctor?
What doctor has records? Name, Address, Phone number]
25. Additional Comments:
PARAGON LIFE INSURANCE COMPANY
100 SOUTH BRENTWOOD
ST. LOUIS, MO 63105
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
ACKNOWLEDGEMENT AND AUTHORIZATION
- --------------------------------------------------------------------------------
I have read all the questions and answers in this Application Part II and any
amendments to it including any supplements and they are true, complete and
correctly recorded. I agree to give Paragon Life Insurance Company written
notice of any change in my health or habits that occurs after signing this
Application Part II, but before receiving the policy and paying the first
premium, if not already paid.
I agree that:
1. This Application Part II, the Life Application Part I, and any amendments
will be the basis for and will be part of the policy issued;
2. No agent or medical/paramedical examiner has authority to alter the
Company's rules or requirements, this Application Part II, or the policy;
3. If a premium payment was given in exchange for a Temporary Insurance
Agreement (TIA), the Company will be liable only as set forth in that
Agreement. If a premium payment was not given, then insurance will take
effect when a policy is approved by the Company for issue as applied for,
the first full premium is paid, and the health and insurability of any
person proposed for insurance have not changed since the date of the
application. If a policy is issued other than as applied for, insurance
will take effect under the policy only when a policy issued by the Company
is delivered to and accepted by me, the first full premium is paid, and
the health and insurability of any person proposed for insurance have not
changed since the date of this application.
- --------------------------------------------------------------------------------
Dated at _______________________________________________ Date________________
(City, State)
Signature of Proposed Insured __________________________________________________
(Parent or Guardian if Proposed Insured under age 18)
- --------------------------------------------------------------------------------
When will additional questions not be asked?
---
Question 4 If answered "Yes", additional questions will not be asked.
Question 5 If answered "No", additional questions will not be asked.
Question 6 If answered "No", additional questions will not be asked.
Question 7 If answered "No", additional questions will not be asked.
Question 8 If answered "No", additional questions will not be asked.
Question 9 If answered "No", additional questions will not be asked.
Question 10 If answered "No", additional questions will not be asked.
Question 11 If answered "No", additional questions will not be asked.
Question 12a If answered "No", additional questions will not be asked.
Question l2b If answered "No", additional questions will not be asked.
Question 13 If answered "No", additional questions will not be asked.
If answered "Yes", questions pertaining only to that topic will be
asked. For example, if the proposed insured indicates that he
participates only in motor vehicle racing, the questions
pertaining to sky sports, motorboat, underwater diving, and
mountain or rock climbing will not be asked.
Question 14 If answered "None", additional questions will not be asked.
Question 15c If answered "No", additional questions will not be asked.
Question 16 If answered "No", additional questions will not be asked.
Question 17 If answered "No", additional questions will not be asked.
Question 18a If answered "Yes", additional questions will not be asked.
Question 18b If answered "No", additional questions will not be asked.
Question 19a If answered "No", additional questions will not be asked. If
answered "Yes", questions pertaining only to that topic will be
asked. For example, if the proposed insured indicates that he has
been diagnosed as having only cancer, the questions pertaining to
disorder of the blood, stroke, and diabetes will not be asked.
Question 19b If answered "No", additional questions will not be asked. If
answered "Yes", questions pertaining only to that topic will be
asked. For example, if the proposed insured indicates that he has
been diagnosed as having high blood pressure and chest pain, the
questions pertaining to heart attack and other disease or disorder
of the heart or circulatory system will not be asked.
Question 19c If answered "No", additional questions will not be asked. If
answered "Yes", questions pertaining only to that topic will be
asked. For example, if the proposed insured indicates that he has
been diagnosed as having only asthma, the questions pertaining to
emphysema and other disease or disorder of the lungs or
respiratory system will not be asked.
Question 19d If answered "No", additional questions will not be asked. If
answered "Yes", questions pertaining only to that topic will be
asked. For example, if the proposed insured indicates that he has
been diagnosed as having only cirrhosis, the questions pertaining
to hepatitis and other disease of disorder of the liver will not
be asked.
Question 19e If answered "No", additional questions will not be asked. If
answered "Yes", questions pertaining only to that topic will be
asked. For example, if the proposed insured indicates that he has
been diagnosed as having a disease or disorder of the intestines,
the questions pertaining to disease or disorder of the stomach,
kidney, bladder, and prostate will not be asked.
Question 19f If answered "No", additional questions will not be asked. If
answered "Yes", questions pertaining only to that topic will be
asked. For example, if the proposed insured indicates that he has
been diagnosed as having depression, stress, or anxiety, the
questions pertaining to other psychological or emotional disorder
or symptoms will not be asked.
Question 20a If answered "No", additional questions will not be asked
Question 20b If answered "No", additional questions will not be asked. If
answered "Yes", questions pertaining only to that topic will be
asked. For example, if the proposed insured indicates that he has
had a checkup, the questions pertaining to illness, injury, health
condition, treatment, hospitalization, surgery and medical tests
will not be asked.
Question 21a If answered "No", additional questions will not be asked.
Question 21b If answered "No", additional questions will not be asked.
Question 22a If answered "No", additional questions will not be asked.
Question 22b If answered "No", additional questions will not be asked.
Question 23 If answered "No", additional questions will not be asked. If
answered "Yes", questions pertaining only to that topic will be
asked. For example, if the proposed insured indicates that he is
currently taking medication, the questions pertaining to been
advised to take medication will not be asked.
Question 24 If answered "No", additional questions will not be asked. If
answered "Yes", questions pertaining only to that topic will be
asked. For example, if the proposed insured indicates that he has
a mental impairment or disease, the questions pertaining to
physical impairment or disease will not be asked.