National Insurance Agency: JCMS Business Overhead Expense Insurance Application

American General Assurance Company,
Member American General Financial Group

APPLICATION FOR DISABILITY AND BUSINESS OVERHEAD EXPENSE INSURANCE

For Office Use Only • Policy No.

Name of Organization __________________________________________

Your Name _______________________________________	Male Female	Soc. Sec. No._____________

Billing
Address _____________________________________________________________________________________

Street

_____________________________________________________ Phone Number ___________________

City State Zip

Beneficiary ______________________________ Relationship_____________________________

Are you now working at least 30 hours per week with your present employer? Yes No Occupation _____________________

.

I WOULD LIKE TO APPLY FOR DISABILITY INCOME INSURANCE

I WOULD LIKE TO APPLY FOR BUSINESS OVERHEAD EXPENSE INSURANCE

My annual earned income for 12 months immediately preceding the date of this application is $__________
Average monthly amount of eligible overhead expenses in the preceding six months? Per Month $___________________

Type of Organization:Proprietorship Corporation Partnership

Indicate the monthly benefit desired: (in $100 increments) If Corporation or Partnership, my share of the eligible expenses is ________%

$________________________________________ Indicate the monthly benefit desired: (in $100 increments)

Indicate Waiting Period: $___________________________________________

30 Day 60 Day 90 Day 180 Day 365 Day Indicate Waiting Period:

Benefit Period: 15 Day 30 Day

Benefit Period: 24 MONTHS

Premiums to be paid: Annually Semi•Annually

HEALTH SECTION (must be completed in full prior to any underwriting consideration)

Birth
Date ________________ Birth
Place ___________________ Height
Ft. _____________ In. _____________ Weight
lb. ______________

1. Have you ever had or been treated for: (Circle Specific disorders experienced)

a. Heart trouble or murmur, chest pain, rheumatic fever, elevated blood pressure, stroke? Yes No

b. Injury, pain or disorder of neck or back? Sciatica? Any disabling injury? Yes No

c. Arthritis, gout, bursitis or rheumatism? Yes No

d. Dizziness, epilepsy, convulsions, recurrent headaches, glaucoma, cataract, or other disorder of the eyes or ears? Yes No

e. Disease or disorder of rectum or anus, Varicose veins, or other vascular disorder? Yes No

f. Diabetes? Sugar, albumin, or pus in urine? Thyroid or other glandular disorder? Yes No

g. Duodenal or stomach ulcer, or other disorder of stomach, liver, gall bladder? Colitis, diverticulitis, or other disorder of small or large intestine? Yes No

h. Prostrate disorder? Kidney stone or colic, nephritis, nephrosis, or other kidney disorders? Urinary infection? Yes No

i. Menstrual, uterine, or ovarian disorder, disorder of the breast? Yes No

j. Bronchitis, emphysema, pleurisy, difficult breathing, blood spitting, or other disorder of lung or nose? Yes No

k. Cancer or other tumor? Deformity or loss of limb? Congenital defect? Yes No

l. Mental or emotional problems requiring help of a physician or psychologist? Yes No

m. A surgical operation? A surgical operation advised but not performed? Yes No

2. Have you ever had treatment by or consultation with any hospital, institution, physician, or practitioner within the past 5 years? Yes No

If you answered “yes” to questions 1a-m or 2, please explain fully in the chart below. Should you require additional space, please use a separate sheet of paper and attach it to this form. (Please Sign and Date)

Question
# Condition Date
Occurred Duration Degree of
Recovery Names & Addresses of Hospitals,
Physicians or Clinic Consulted

FORM S-10555

DISCLOSURE NOTICE – MEDICAL INFORMATION BUREAU
Information regarding your insurability will be treated as confidential. American General Assurance Company (AGAC), or its re-insurers, may, however, make a brief report to the Medical Information Bureau. The Bureau is a non–profit membership organization of life insurance companies that operates an information exchange on behalf of its members. If you apply to another Bureau member company for life or health insurance coverage, or submit a claim for benefits to such company, the bureau, upon request, will supply such company with the information in its files. Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in its files. if you question the accuracy of information in the Bureau’s files, you may contact the Bureau and seek a correction in accordance with the procedures set forth in the Fair Credit Reporting Act.
The address of the Bureau’s information office is: P.O. Box 105, Essex Station, Boston, MA 02112. Telephone number is (617) 426–3660.
AGAC, or its re-insurers, may also release information in its files to other life insurance companies to whom you apply for life or health insurance, or to whom a claim for benefits may be submitted.

What other Disability Insurance or Business Overhead Expense Insurance do you now carry or have an application pending for: (Give Full Details)



  Insurance Company Amount of Monthly Benefit Accident    How long are Benefits Payable?    Sickness

   Are you replacing any current income or business overhead expense coverage you have? Yes No

    If Yes, provide name of Insurance Company and Policy Number  _______________________________________________

    _____________________________________________________________________________________________

DECLARATION OF MEMBER GIVING STATEMENT OF INSURABILITY

1. To the best of my knowledge and belief, all statements made on this application are true and complete.

2. I understand that my application for insurance will be accepted or declined on the basis of these statements.

AUTHORIZATION

I authorize the sources stated on the MIB Disclosure to give to AGAC, or any consumer reporting agency acting on its behalf, information about me. Such information will pertain to my employment, other insurance coverage, and medical care, advice, treatment or supplies for any physical or mental condition. Authorized sources are: any physician or medical professional, any hospital, clinic, or other medical care institution; any insurer, the Medical Information Bureau; any consumer reporting agency; any employer. I understand that this information will be used by AGAC to determine eligibility for insurance.
I understand that I may revoke this authorization at any time. I agree that such revocation will not affect any action which AGAC has taken in reliance on the authorization. I understand that this authorization will not be valid after 30 months, if not revoked earlier. I know that I have the right to receive a copy of this authorization if I request one. I agree that a photocopy of this authorization is as valid as the original.

FRAUD STATEMENT

Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

Date ________________________________________	Signature of Member _________________________________

Signature of Agent ____________________________________________________

Underwritten by: American General Assurance Company

FORM S–10555

Billing Address	_____________________________________________________________________________________
	Street
	_____________________________________________________			Phone Number ___________________
	City	State	Zip
Beneficiary ______________________________			Relationship_____________________________


	Are you now working at least 30 hours per week with your present employer? Yes No	Occupation _____________________


1.	Have you ever had or been treated for: (Circle Specific disorders experienced)
	a.	Heart trouble or murmur, chest pain, rheumatic fever, elevated blood pressure, stroke?	Yes	No
	b.	Injury, pain or disorder of neck or back? Sciatica? Any disabling injury?	Yes	No
	c.	Arthritis, gout, bursitis or rheumatism?	Yes	No
	d.	Dizziness, epilepsy, convulsions, recurrent headaches, glaucoma, cataract, or other disorder of the eyes or ears?	Yes	No
	e.	Disease or disorder of rectum or anus, Varicose veins, or other vascular disorder?	Yes	No
	f.	Diabetes? Sugar, albumin, or pus in urine? Thyroid or other glandular disorder?	Yes	No
	g.	Duodenal or stomach ulcer, or other disorder of stomach, liver, gall bladder? Colitis, diverticulitis, or other disorder of small or large intestine?	Yes	No
	h.	Prostrate disorder? Kidney stone or colic, nephritis, nephrosis, or other kidney disorders? Urinary infection?	Yes	No
	i.	Menstrual, uterine, or ovarian disorder, disorder of the breast?	Yes	No
	j.	Bronchitis, emphysema, pleurisy, difficult breathing, blood spitting, or other disorder of lung or nose?	Yes	No
	k.	Cancer or other tumor? Deformity or loss of limb? Congenital defect?	Yes	No
	l.	Mental or emotional problems requiring help of a physician or psychologist?	Yes	No
	m.	A surgical operation? A surgical operation advised but not performed?	Yes	No

2.	Have you ever had treatment by or consultation with any hospital, institution, physician, or practitioner within the past 5 years?	Yes	No
	If you answered “yes” to questions 1a-m or 2, please explain fully in the chart below. Should you require additional space, please use a separate sheet of paper and attach it to this form. (Please Sign and Date)

	If Yes, provide name of Insurance Company and Policy Number _______________________________________________

	_____________________________________________________________________________________________

1.	To the best of my knowledge and belief, all statements made on this application are true and complete.
2.	I understand that my application for insurance will be accepted or declined on the basis of these statements.

AUTHORIZATION
I authorize the sources stated on the MIB Disclosure to give to AGAC, or any consumer reporting agency acting on its behalf, information about me. Such information will pertain to my employment, other insurance coverage, and medical care, advice, treatment or supplies for any physical or mental condition. Authorized sources are: any physician or medical professional, any hospital, clinic, or other medical care institution; any insurer, the Medical Information Bureau; any consumer reporting agency; any employer. I understand that this information will be used by AGAC to determine eligibility for insurance. I understand that I may revoke this authorization at any time. I agree that such revocation will not affect any action which AGAC has taken in reliance on the authorization. I understand that this authorization will not be valid after 30 months, if not revoked earlier. I know that I have the right to receive a copy of this authorization if I request one. I agree that a photocopy of this authorization is as valid as the original.

FRAUD STATEMENT
Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.