Page 3 - Application-Sample-Booklet_Texas

LUMP SUM CANCER and/or Phone Verification Case # _______________
HEART & STROKE INSURANCE POLICIES

Insured by Loyal American Life Insurance Company®

PO Box 559015, Austin, TX 78755-9015 • (866) 459-4272

Application for Insurance

Section I. Coverage Options

1. Applying for: New Coverage Reinstatement Change in Benefit Coverage
Add Dependent(s) to existing policy*
Add Rider(s) to existing policy*

*Policyowner’s Name ___________________________________________________

2. Requested Effective Date ______________________________

Section II. Applicant(s) applying for coverage

Last Name First Name M. I. Age Date of Birth Gender Social Security
Primary Applicant Ht. (ft.-in.) (MM/DD/YYYY) Number

Male
Female

Spouse Male
Female

Child 1 Male
Female

Child 2 Male
Female

Child 3 Male
Female

Child 4 Male
Female

Applicant Spouse
Wt. (lbs.)
Ht. (ft.-in.) Wt. (lbs.)

Section III. Primary Applicant’s Information Mailing Address (if different from Home Address):
Street/PO Box
Home Address Required:
Street/PO Box

City State Zip Code City State Zip Code

Preferred Email Address

Cell Phone ( ) Home Phone ( ) Work Phone ( )

Section IV. Beneficiary Information: Please provide beneficiary information for the Primary Applicant and Spouse if applicable. The Primary
Applicant will automatically be named the beneficiary for Child(ren) named in the Application.

Applicant Name Name of Beneficiary Date of Birth Relationship to Primary or Percentage
(MM/DD/YYYY) Applicant Contingent of Benefit

LY-LSCH-APP-B-FL Page 1 of 5 09/14