Page 4 - Application-Sample-Booklet_Texas
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Section V. Premium Payment Method
Select one of the following:
Electronic Funds Transfer (Bank Draft) (complete the Electronic Funds Transfer Authorization form)
Premium Mode: Monthly Quarterly Semi-annually Annually
Direct Bill Quarterly Semi-annually Annually
Premium Mode:
Section VI. Benefit Selection
Coverage type: Individual Individual & Spouse One-Parent Family Family
Policy selection: Lump Sum Cancer Policy Benefit Amount $____________ Policy Modal Premium $____________
Lump Sum Heart/Stroke Policy Benefit Amount $____________ Policy Modal Premium $____________
Optional Rider selection (for an additional premium):
Heart and Stroke Restoration Benefit Rider Rider Modal Premium $____________
(can only be sold with Lump Sum Heart/Stroke Policy)
Lump Sum Cancer Rider Benefit Amount $____________ Rider Modal Premium $____________
(cannot be sold with the Lump Sum Cancer Policy)
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 $____________
Hospital and Intensive Care Unit Indemnity Rider (max issue age 99)
(cannot be sold with the Hospital Indemnity Rider or the Intensive Care Unit Rider)
Benefit Amount* $__________ Rider Modal Premium $____________
*Benefits reduce to 50% of the amount selected at age 65 or older
Return of Premium upon Death Rider (max issue age 74) Rider Modal Premium $____________
Total Policy and Optional Rider(s) Modal Premium $____________
Check enclosed (make checks Payable to Loyal American Life Insurance Company)
Draft bank account for first premium
Section VII. Prior or Other Coverage YES NO
1. Is the Insurance applied for here intended to replace any existing or pending accident or sickness insurance? . . . . . . . . . . . .
If YES, please provide the following (complete the Replacement Notice):
Name of Company ____________________________________________ Policy Number ____________________
2. Is any Applicant eligible for Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Is any Applicant currently covered by any Title XIX program (Medicaid or any similar name)? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If YES, any person this applies to is not eligible for coverage.
LY-LSCH-APP-B-FL Page 2 of 5 09/14
Select one of the following:
Electronic Funds Transfer (Bank Draft) (complete the Electronic Funds Transfer Authorization form)
Premium Mode: Monthly Quarterly Semi-annually Annually
Direct Bill Quarterly Semi-annually Annually
Premium Mode:
Section VI. Benefit Selection
Coverage type: Individual Individual & Spouse One-Parent Family Family
Policy selection: Lump Sum Cancer Policy Benefit Amount $____________ Policy Modal Premium $____________
Lump Sum Heart/Stroke Policy Benefit Amount $____________ Policy Modal Premium $____________
Optional Rider selection (for an additional premium):
Heart and Stroke Restoration Benefit Rider Rider Modal Premium $____________
(can only be sold with Lump Sum Heart/Stroke Policy)
Lump Sum Cancer Rider Benefit Amount $____________ Rider Modal Premium $____________
(cannot be sold with the Lump Sum Cancer Policy)
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 $____________
Hospital and Intensive Care Unit Indemnity Rider (max issue age 99)
(cannot be sold with the Hospital Indemnity Rider or the Intensive Care Unit Rider)
Benefit Amount* $__________ Rider Modal Premium $____________
*Benefits reduce to 50% of the amount selected at age 65 or older
Return of Premium upon Death Rider (max issue age 74) Rider Modal Premium $____________
Total Policy and Optional Rider(s) Modal Premium $____________
Check enclosed (make checks Payable to Loyal American Life Insurance Company)
Draft bank account for first premium
Section VII. Prior or Other Coverage YES NO
1. Is the Insurance applied for here intended to replace any existing or pending accident or sickness insurance? . . . . . . . . . . . .
If YES, please provide the following (complete the Replacement Notice):
Name of Company ____________________________________________ Policy Number ____________________
2. Is any Applicant eligible for Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Is any Applicant currently covered by any Title XIX program (Medicaid or any similar name)? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If YES, any person this applies to is not eligible for coverage.
LY-LSCH-APP-B-FL Page 2 of 5 09/14
