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Section IX. Policyowner’s Statements and Agreements
I hereby apply to Loyal American Life Insurance Company for insurance coverage to be issued based upon the truth and completeness of the
answers to the above questions and understand and agree that: (1) no Agent has the authority to waive the answer to any questions on the
Application; (2) no insurance will be effective until (a) this signed Application has been accepted upon review of the answers I have provided
and any medical information reviewed by Loyal, (b) the initial premium has been paid, and (c) a contract has been issued by Loyal American
Life Insurance Company; and (3) I have received the Outline of Coverage for the policy applied for, the Replacement Notice form, if applicable,
and, if eligible for Medicare, the required Guide to Health Insurance for People with Medicare.
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing
any false, incomplete, or misleading information is guilty of a felony of the third degree.
The Primary Applicant must sign and date, acknowledging their understanding and agreement to the conditions listed herein. To the best of
my knowledge and belief, the above statements are true and complete:
I understand and agree that for all Applicants these statements shall be the basis for determination of acceptance for coverage under my
applicable Loyal policy. I acknowledge and agree that any material misrepresentation or material omission of any Applicant may render this
contract null and void from its date of issue in accordance with applicable law. If coverage is revoked, I will receive written notice that will
explain the decision and my right to appeal. Loyal will return all paid premiums and fees less any claim payments.
As an alternative to court action, any matter in dispute between me and the Company may be subject to voluntary arbitration governed by
the provisions of the Commercial Arbitration Rules of the American Health Lawyers Association. Any decision reached by arbitration shall be
binding upon both myself and the Company and may be entered as a judgment in any court of proper jurisdiction.
Any Applicant who is currently covered by Medicaid should not purchase this coverage.
WAITING PERIOD: The Lump Sum Heart & Stroke Policy/Rider has a thirty (30) day Waiting Period which begins on the issue date. No benefits
will be paid for a Qualifying Event that is Diagnosed during the Waiting Period. WAITING PERIOD means the first thirty (30) days following an
Insured Person’s issue date.
I understand that the Lump Sum Cancer Policy/Rider, Lump Sum Heart/Stroke Policy/Rider, Hospital Indemnity Rider, Intensive Care Unit Rider,
and Hospital and Intensive Care Unit Indemnity Rider will not pay benefits for the first twelve (12) months after the issue date for any loss
caused by a pre-existing condition which I or any Applicant have had in the past six (6) months. PRE-EXISTING condition means a condition
Diagnosed or for which medical Advice or Treatment was recommended by or received from a Physician within the six (6) months prior to the
issue date.
In the event that I am applying for the Hospital Indemnity Benefit Rider, Intensive Care Unit Benefit Rider, or
Hospital Indemnity and Intensive Care Unit Benefit Rider, the following disclosure and attestation apply:
THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL
COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE)
MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES.
I hereby attest that I have other health coverage that is minimum essential coverage within the meaning of section 5000A(f) of the Internal
Revenue Code, or that I am treated as having minimum essential coverage due to my status as a bona fide resident of any possession of the
United States pursuant to Code section 5000A(f)(4)(B).
Primary Applicant’s Signature or Parent or Guardian if Applicant is a minor (Policyowner) Today’s Date (MM/DD/YYYY)
LY-LSCH-APP-B-FL Page 4 of 5 09/14
I hereby apply to Loyal American Life Insurance Company for insurance coverage to be issued based upon the truth and completeness of the
answers to the above questions and understand and agree that: (1) no Agent has the authority to waive the answer to any questions on the
Application; (2) no insurance will be effective until (a) this signed Application has been accepted upon review of the answers I have provided
and any medical information reviewed by Loyal, (b) the initial premium has been paid, and (c) a contract has been issued by Loyal American
Life Insurance Company; and (3) I have received the Outline of Coverage for the policy applied for, the Replacement Notice form, if applicable,
and, if eligible for Medicare, the required Guide to Health Insurance for People with Medicare.
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing
any false, incomplete, or misleading information is guilty of a felony of the third degree.
The Primary Applicant must sign and date, acknowledging their understanding and agreement to the conditions listed herein. To the best of
my knowledge and belief, the above statements are true and complete:
I understand and agree that for all Applicants these statements shall be the basis for determination of acceptance for coverage under my
applicable Loyal policy. I acknowledge and agree that any material misrepresentation or material omission of any Applicant may render this
contract null and void from its date of issue in accordance with applicable law. If coverage is revoked, I will receive written notice that will
explain the decision and my right to appeal. Loyal will return all paid premiums and fees less any claim payments.
As an alternative to court action, any matter in dispute between me and the Company may be subject to voluntary arbitration governed by
the provisions of the Commercial Arbitration Rules of the American Health Lawyers Association. Any decision reached by arbitration shall be
binding upon both myself and the Company and may be entered as a judgment in any court of proper jurisdiction.
Any Applicant who is currently covered by Medicaid should not purchase this coverage.
WAITING PERIOD: The Lump Sum Heart & Stroke Policy/Rider has a thirty (30) day Waiting Period which begins on the issue date. No benefits
will be paid for a Qualifying Event that is Diagnosed during the Waiting Period. WAITING PERIOD means the first thirty (30) days following an
Insured Person’s issue date.
I understand that the Lump Sum Cancer Policy/Rider, Lump Sum Heart/Stroke Policy/Rider, Hospital Indemnity Rider, Intensive Care Unit Rider,
and Hospital and Intensive Care Unit Indemnity Rider will not pay benefits for the first twelve (12) months after the issue date for any loss
caused by a pre-existing condition which I or any Applicant have had in the past six (6) months. PRE-EXISTING condition means a condition
Diagnosed or for which medical Advice or Treatment was recommended by or received from a Physician within the six (6) months prior to the
issue date.
In the event that I am applying for the Hospital Indemnity Benefit Rider, Intensive Care Unit Benefit Rider, or
Hospital Indemnity and Intensive Care Unit Benefit Rider, the following disclosure and attestation apply:
THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL
COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE)
MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES.
I hereby attest that I have other health coverage that is minimum essential coverage within the meaning of section 5000A(f) of the Internal
Revenue Code, or that I am treated as having minimum essential coverage due to my status as a bona fide resident of any possession of the
United States pursuant to Code section 5000A(f)(4)(B).
Primary Applicant’s Signature or Parent or Guardian if Applicant is a minor (Policyowner) Today’s Date (MM/DD/YYYY)
LY-LSCH-APP-B-FL Page 4 of 5 09/14
