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LUMP SUM CANCER and/or
HEART & STROKE INSURANCE POLICIES
Insured by Loyal American Life Insurance Company®
PO Box 559015, Austin, TX 78755-9015 • (866) 459-4272
Application Policy/Rider Instructions
Please indicate in the benefit selection section of the application where to apply the Hospital Indemnity Rider, Intensive Care Unit Rider,
Hospital and Intensive Care Unit Indemnity Rider, and/or Return of Premium Riders.
Example provided below
In this situation, the Hospital and ICU Indemnity rider is to be applied to the Lump Sum Cancer base and the Return of Premium Rider is to be
applied to both the Lump Sum Cancer base and the Lump Sum Heart/Stroke base.
Section VII. Benefit Selection
Coverage type: X Individual Individual & Spouse One-Parent Family Family
Benefit Amount $_5__,0__0___0____ Policy Modal Premium $____________
Benefit Amount $_5__,_0__0__0____ Policy Modal Premium $____________
PLE(cannot be sold with the Lump Sum Cancer Policy)Policy selection:X Lump Sum Cancer Policy
X Lump Sum Heart/Stroke Policy
Optional Rider selection (for an additional premium): Rider Modal Premium $____________
X Cancer Recurrence Benefit Rider
(can only be sold with Lump Sum Cancer Policy)
X Heart and Stroke Restoration Benefit Rider Rider Modal Premium $____________
(can only be sold with Lump Sum Heart/Stroke Policy)
SAMX Hospital and Intensive Care Unit Indemnity Rider (max issue age 99)
Lump Sum Cancer Rider Benefit Amount $____________ Rider Modal Premium $____________
Lump Sum Heart/Stroke Rider Benefit Amount $____________ Rider Modal Premium $____________
(cannot be sold with Lump Sum Heart/Stroke Policy)
Hospital Indemnity Rider (max issue age 99) Benefit Amount* $____________ Rider Modal Premium $____________
Intensive Care Unit Rider (max issue age 99) Benefit Amount* $____________ Rider Modal Premium $____________
(cannot be sold with the Hospital Indemnity Rider or the Intensive Care Unit Rider)
Bene t Amount* $_1_0__0______ Rider Modal Premium $____________
Apply to Cancer Policy
*Benefits reduce to 50% of the amount selected at age 65 or older
X Return of Premium upon Death Rider (max issue age 74) Rider Modal Premium $____________
Apply to Cancer AND HEART Policy Total Policy and Optional Riders Modal Premium $____________
(Be sure to calculate additional ROP premium for each
policy selected.)
Check enclosed (make checks Payable to Loyal American Life Insurance Company)
Draft bank account for first premium
If the maximum benefit is paid on the base policy, the policy will not terminate if additional riders are attached under which benefits are
still eligible for payment. Lump Sum riders may be converted to a policy, since riders cannot stand alone. The insured must continue paying
premium on the base policy for the riders to remain.
If there is no indication on the application as to which base the rider should be applied to, an RFI will be sent out for clarification, which could
delay processing.
Note: Not all riders are available in all states. Your actual state application may vary from the sample shown above.
LOYAL-9-0038 11/14
HEART & STROKE INSURANCE POLICIES
Insured by Loyal American Life Insurance Company®
PO Box 559015, Austin, TX 78755-9015 • (866) 459-4272
Application Policy/Rider Instructions
Please indicate in the benefit selection section of the application where to apply the Hospital Indemnity Rider, Intensive Care Unit Rider,
Hospital and Intensive Care Unit Indemnity Rider, and/or Return of Premium Riders.
Example provided below
In this situation, the Hospital and ICU Indemnity rider is to be applied to the Lump Sum Cancer base and the Return of Premium Rider is to be
applied to both the Lump Sum Cancer base and the Lump Sum Heart/Stroke base.
Section VII. Benefit Selection
Coverage type: X Individual Individual & Spouse One-Parent Family Family
Benefit Amount $_5__,0__0___0____ Policy Modal Premium $____________
Benefit Amount $_5__,_0__0__0____ Policy Modal Premium $____________
PLE(cannot be sold with the Lump Sum Cancer Policy)Policy selection:X Lump Sum Cancer Policy
X Lump Sum Heart/Stroke Policy
Optional Rider selection (for an additional premium): Rider Modal Premium $____________
X Cancer Recurrence Benefit Rider
(can only be sold with Lump Sum Cancer Policy)
X Heart and Stroke Restoration Benefit Rider Rider Modal Premium $____________
(can only be sold with Lump Sum Heart/Stroke Policy)
SAMX Hospital and Intensive Care Unit Indemnity Rider (max issue age 99)
Lump Sum Cancer Rider Benefit Amount $____________ Rider Modal Premium $____________
Lump Sum Heart/Stroke Rider Benefit Amount $____________ Rider Modal Premium $____________
(cannot be sold with Lump Sum Heart/Stroke Policy)
Hospital Indemnity Rider (max issue age 99) Benefit Amount* $____________ Rider Modal Premium $____________
Intensive Care Unit Rider (max issue age 99) Benefit Amount* $____________ Rider Modal Premium $____________
(cannot be sold with the Hospital Indemnity Rider or the Intensive Care Unit Rider)
Bene t Amount* $_1_0__0______ Rider Modal Premium $____________
Apply to Cancer Policy
*Benefits reduce to 50% of the amount selected at age 65 or older
X Return of Premium upon Death Rider (max issue age 74) Rider Modal Premium $____________
Apply to Cancer AND HEART Policy Total Policy and Optional Riders Modal Premium $____________
(Be sure to calculate additional ROP premium for each
policy selected.)
Check enclosed (make checks Payable to Loyal American Life Insurance Company)
Draft bank account for first premium
If the maximum benefit is paid on the base policy, the policy will not terminate if additional riders are attached under which benefits are
still eligible for payment. Lump Sum riders may be converted to a policy, since riders cannot stand alone. The insured must continue paying
premium on the base policy for the riders to remain.
If there is no indication on the application as to which base the rider should be applied to, an RFI will be sent out for clarification, which could
delay processing.
Note: Not all riders are available in all states. Your actual state application may vary from the sample shown above.
LOYAL-9-0038 11/14
