AIG Reinstatement Application for Life Insurance Form – Fill Out and Use This PDF

Reinstatement Application for Life Insurance

Maine Version

American General Life Insurance Company, Houston, TX

The United States Life Insurance Company in the City of New York, New York, NY (Non-NY Residents)

P.O. Box 4373 • Houston, TX 77210-4373 • Fax #: 713-831-3028

The insurance company checked above is solely responsible for the obligation and payment of benefits under any policy it may issue. No other company shown is responsible for such obligations or payments.

Policy Number(s)		__________________________________________________________________________________
SECTION I – GENERAL INFORMATION:
A. PRIMARY INSURED
First Name __________________________ MI ____			Last Name______________________ Social Security # ________________
Sex M	F	Birthplace (state, country) __________________________________________ Date of Birth ______________
U.S. Citizen or Permanent Resident (Green Card holder)			yes no

If no, Country of Citizenship ________________________ Date of Entry __________ Visa Type __________ (Copy of Visa Required)

CHECK HERE IF NEW ADDRESS

Address __________________________________________ City, State ____________________________ Zip ____________

Home Phone________________________ Alternate Phone________________________ Email ____________________________

Employer ________________________________________________ Occupation ____________________________________

Personal Earned Income $ ______________________ Net Worth $ ______________________

Personal Earned Income means salary, wages, commissions, fees, or other earned income received during the last 12 months, reduced by regular business expenses, but before all other deductions.

B.OTHER INSURED Complete if spouse or additional insured covered under the policy

First Name __________________________ MI ____				Last Name______________________ Social Security # ________________
Sex	M	F	Birthplace (state, country) __________________________________________ Date of Birth ______________
U.S. Citizen or Permanent Resident (Green Card holder)				yes	no

If no, Country of Citizenship ________________________ Date of Entry __________ Visa Type __________ (Copy of Visa Required)

Address __________________________________________ City, State ____________________________ Zip ____________

Home Phone________________________ Alternate Phone________________________ Email ____________________________

Employer ________________________________________________ Occupation ____________________________________

Personal Earned Income $ ______________________ Net Worth $ ______________________

Personal Earned Income means salary, wages, commissions, fees, or other earned income received during the last 12 months, reduced by regular business expenses, but before all other deductions.

C. CHILD INFORMATION Complete information for all children covered by child rider
Child Name	Sex		Date of Birth
______________________________________________________________________	M	F	______________________
______________________________________________________________________	M	F	______________________
______________________________________________________________________	M	F	______________________

AGLC100440-ME-2011

Page 1 of 4

Rev0113

D.OWNER INFORMATION Complete if the primary insured is not the owner

First Name __________________________ MI ____ Last Name______________________ Tax ID #________________________

CHECK HERE IF NEW ADDRESS

Address __________________________________________ City, State ____________________________ Zip ____________

Home Phone________________________ Alternate Phone________________________ Email ____________________________

If owner is a trust please designate information for the Name, Tax ID, Current Trustee and Date of Trust in the Special Remarks section.

E. PREMIUM PAYMENT ENCLOSED

yes noAmount $ ____________________________ Check # ____________________

SECONDARY ADDRESSEE

Name ______________________________________________________________________________________________________

Social Security or Tax ID# __________________________________________Home Phone (____) __________________________

Address __________________________________________ City, State ____________________________ Zip ____________

SECTION II:

A. BACKGROUND INFORMATION – For all covered persons

Complete questions 1 through 12 for all proposed insureds who are covered by this policy. If an answer of yes applies to ANY insured provide details. You may be asked to complete and submit an additional form.

1. Tobacco Use: Have you ever used any form of tobacco or nicotine products?	yes	no
If yes, type and quantity _________________________________________________ Are you a current user?	yes	no
If not a current user, date of last use __________

2.Have you ever used cocaine, marijuana, heroin, controlled substances or any other drug, except as legally

prescribed by a physician?

yes

no

3.Have you ever sought or received advice, counseling or treatment by a medical professional for the use of

alcohol or drugs, including prescription drugs?	yes	no
4. Driver's License State: ______________________________	Number: ______________________________
In the past five years, have you been charged with or convicted of any driving violations to include driving
under the influence of alcohol or drugs?	yes	no

5.In the past five years, have you participated in, or do you intend to participate in: any flights as a trainee, pilot or crew member; scuba diving; skydiving or parachuting; ultralight aviation; auto racing; cave

	exploration; hang gliding; boat racing; mountaineering; extreme sports or other hazardous activities?	yes	no
6.	Do you intend to travel or reside outside of the United States or Canada within the next two years?	yes	no
7.	Have you ever requested or received a pension, benefits, or payments because of an injury, sickness, or disability?	yes	no
8.	Have you ever filed for bankruptcy?	yes	no

9.Have you ever been convicted of or pled guilty or no contest to a criminal offense or currently have any

felony or misdemeanor charge pending?

yes

no

10.Is there an intention that any party, other than the Owner, will obtain any right, title, or interest in any policy

issued on the life of any Proposed Insured as a result of this application?

yes

no

11.Does the Owner or any Proposed Insured intend to finance any of the premium required to pay for this policy

through a financing or loan agreement?

yes

no

12.Is the Owner, any Proposed Insured, or any person or entity, being paid (cash, services, etc) as an incentive

to enter into this transaction?

yes

no

Details:

B. EXISTING COVERAGE

1. Does any Proposed Insured have any existing life insurance policies?yes no

2. If question 1 is answered "yes", please provide the following information:

Name of	Type	Year	Face	Insurance	Contract or
Proposed Insured	(see below)	of Issue	Amount	Company	Policy #

___________________________ __________________ _________ _________ ____________________ ________________

___________________________ __________________ _________ _________ ____________________ ________________

Type: i= individual, b= business, g= group

AGLC100440-ME-2011

Page 2 of 4

Rev0113

C. MEDICAL INFORMATION
1. Primary Insured: Height ____ft ____in	Weight ____ lbs	Change of weight in last year?	None	Gain: ____ lbs	Loss: ____ lbs
Other Insured: Height ____ft ____in	Weight ____ lbs	Change of weight in last year?	None	Gain: ____ lbs	Loss: ____ lbs

2.Name and address of personal physician

Primary Insured: ________________________________________________________________________________________

Other Insured: __________________________________________________________________________________________

3.Date, reason, findings and treatment at last visit

Primary Insured: ________________________________________________________________________________________

Other Insured: __________________________________________________________________________________________

Complete questions 4 through 8 for all proposed insureds who are covered by this policy. If an answer of yes applies to ANY insured provide details such as date of first diagnosis, name and address of doctor, tests performed, test results, medication(s) or recommended treatment.

4. Have you ever been diagnosed as having, been treated for, or consulted a licensed health care provider for:

a.heart disease, heart attack, chest pain, irregular heartbeat, heart murmur, high cholesterol, high blood

pressure or other disorder of the heart?	yes	no
b. a blood clot, aneurysm, stroke, or other disease, disorder or blockage of the arteries or veins?	yes	no
c. cancer, tumors, masses, cysts or other such abnormalities? (except if HIV-related)	yes	no

d.diabetes, a disorder of the thyroid or other glands or a disorder of the immune system, blood

	or lymphatic system? (except if HIV-related)	yes	no
e. colitis, hepatitis or a disorder of the esophagus, stomach, liver, pancreas, gall bladder or intestine?		yes	no
f.	a disorder of the kidneys, bladder, prostate or reproductive organs or protein in the urine?	yes	no
g.	asthma, bronchitis, emphysema, sleep apnea or other breathing or lung disorder?	yes	no

h.seizures, a disorder of the brain or spinal cord or other nervous system abnormality, including

anxiety, depression or other psychiatric conditions?	yes	no
i. arthritis, muscle disorders, connective tissue disease or other bone or joint disorders?	yes	no

Details: ______________________________________________________________________________________________

5. Are you currently taking any medication, treatment or therapy or under medical observation? (except if HIV-related) yes no

Details: ______________________________________________________________________________________________

*This question may be answered "no" if any proposed insured has tested positive for HIV and has not developed symptoms of the disease AIDS.

*6. Have you ever been diagnosed as having or been treated by any member of the medical profession for AIDS
Related Complex (ARC) or Acquired Immune Deficiency Syndrome (AIDS)?	yes no

Details: ______________________________________________________________________________________________

7.Other than previously stated, in the past 10 years have you been advised to have any diagnostic test,

hospitalization, or treatment that was NOT completed? (except if HIV-related)			yes	no
Details:		______________________________________________________________________________________________
8. Do you have any symptoms or knowledge of any other condition that is NOT disclosed above? (except if HIV-related)			yes	no
Details:		______________________________________________________________________________________________

D. SPECIAL REMARKS: Use this space to provide any additional comments or remarks not given in detail above

AGLC100440-ME-2011

Page 3 of 4

Rev0113

AUTHORIZATION AND SIGNATURES

American General Life Insurance Company, Houston, TX

The United States Life Insurance Company in the City of New York, New York, NY

In this application, “Company” refers to the insurance company checked above.

Authorization to Obtain and Disclose Information and Declaration

I give my consent to all of the entities listed below to give to the Company checked above, its legal representative and American General Life Companies LLC ("AGLC") (an affiliated service company) all information they have pertaining to: medical consultations, treatments or surgeries; hospital confinements for any physical and mental conditions; use of drugs or alcohol; drug prescriptions; or any other information; for me, my spouse, or my minor children. This authorization excludes the disclosure of the result of a test for HIV if the applicant has tested HIV positive but has not developed symptoms of the disease AIDS. Such test results shall not be discovered or published. Nothing in this caveat will prohibit this authorization from including the fact that the applicant has AIDS. Other information includes personal finances; habits; hazardous avocations; motor vehicle records from the Department of Motor Vehicles; court records; or foreign travel. I give my consent for the information outlined above to be provided by: any physician or medical practitioner; any hospital, clinic or other health care facility; pharmacy benefit manager or prescription database; any insurance or reinsurance company; any consumer reporting agency or insurance support organization; my employer; or the Medical Information Bureau (MIB).

I understand the information obtained will be used by the Company to determine: (1) eligibility for insurance; and (2) eligibility for benefits under or changes to an existing policy. Any information gathered during the evaluation of my application may be disclosed to: reinsurers; the MIB; other persons or organizations performing business or legal services in connection with my application or claim; me; any physician designated by me; or any person or entity required to receive such information by law or as I may consent.

I, as well as any person authorized to act on my behalf, may, upon written request, obtain a copy of this consent. I understand this consent may be revoked at any time by sending a written request to the Company checked above, Attn: Underwriting Department at P.O. Box 1931, Houston, TX 77251-1931. I understand that this revocation may be a basis for denying insurance coverage. I also understand that failure to sign this consent may impair the Company’s ability to process this application and may be a basis for denying insurance coverage.

This consent will be valid for 24 months from the date of this application. I agree that a copy of this consent will be valid as the original. I authorize the Company checked above and AGLC to obtain an investigative consumer report on me. I understand that I may: request

to be interviewed for the report and receive, upon written request, a copy of such report.

Check if you wish to be interviewed.

I have read the above statements or they have been read to me. They are true and complete to the best of my knowledge and belief. I understand that this application shall be the basis for reinstatement of my coverage. I understand that any misrepresentation contained in this application and related forms and relied on by Company may be used to reduce or deny a claim or void the policy, if it is within its contestable period and if such misrepresentation materially affects the acceptance of the risk. I understand and agree that no insurance will be in effect under this application unless or until approved for reinstatement, the full reinstatement premium for the policy has been paid, and there has been no change in the health of any proposed insured that would change the answers to any questions in the application.

I understand and agree that no agent is authorized to: accept risks or pass upon insurability; make or modify contracts; or waive any of the Company’s rights or requirements.

I have received a copy or have been read the Notices to the Proposed Insured(s).

It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the Company. Penalties may include imprisonment, fines, or a denial of insurance benefits.

IRS Certification: Under penalties of perjury, I certify: (1) that the number shown on this application is my correct Social Security or Tax ID number; and (2) that I am not subject to backup withholding under Section 3406(a)(1)(C) of the Internal Revenue Code; and

(3)that I am a U.S. person (including a U.S. resident alien). The Internal Revenue Service does not require my consent to any provisions of this document other than the certifications required to avoid backup withholding. You must cross out item (2) if you are subject to backup withholding and cross out item (3) if you are not a U.S. person (including a U.S. resident alien).

Signed at (City and State)

Date

Signature of Primary Insured (if under age 15, signature of parent or guardian)

Signature of Other Insured (if under age 15, signature of parent or guardian)

Signature of Owner (if other than insured)

Signature of Officer and Title (if corporate owned)

Signature of Trustee (if owned by a trust)

Agent Name (printed)

Agent Signature

AGLC100440-ME-2011

Page 4 of 4

Rev0113

HIPAA Authorization -

New Business and Inforce Operations

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (“HIPAA”)

Authorization to Obtain and Disclose Information

//

Name of Patient/Proposed Insured (Please Print)		Date of Birth

I hereby authorize all of the people and organizations listed below to give American General Life Insurance Company, The United States Life Insurance Company in the City of New York, and any affiliated services company, (collectively the “Companies”), and their authorized representatives, including agents and insurance support organizations, (collectively, the “Recipient”), the following information:

•any and all information relating to my health (except psychotherapy notes) and my insurance policies and claims, including, but not limited to, information relating to any medical consultations, treatments, or surgeries; hospital confinements for physical and mental conditions; use of drugs or alcohol; drug prescriptions; and communicable diseases including HIV or AIDS; and

•information about me, including my name, address, telephone number, gender and date of birth.

I hereby authorize each of the following entities to provide the information outlined above:

•any physician or medical practitioner;

•any hospital, clinic, other health care facility, pharmacy, or pharmacy benefit manager;

•any insurance or reinsurance company (including, but not limited to, the Recipient or any other American General Life Companies company which may have provided me with life, accident, health, and/or disability insurance coverage, or to which I may have applied for insurance coverage, but coverage was not issued);

•any consumer reporting agency or insurance support organization;

•my employer, group policy holder, or benefit plan administrator; and

•the Medical Information Bureau (MIB).

I understand that the information obtained will be used by the Recipient to:

•determine my eligibility for insurance;

•underwrite my application for insurance;

•determine my eligibility for benefits under any temporary insurance;

•if a policy is issued, determine my eligibility for benefits and contestability of the policy; and

•detect health care fraud or abuse or for compliance activities, which may include disclosure to MIB and participation in MIB's fraud prevention or fraud detection programs.

I hereby acknowledge that the insurance companies listed above are subject to federal privacy regulations. I understand that information released to the Recipient will be used and disclosed as described in the American General Life Companies Notice of Health Information Privacy Practices, but that upon disclosure to any person or organization that is not a health plan or health care provider, the information may no longer be protected by federal privacy regulations.

I may revoke this authorization at any time, except to the extent that action has been taken in reliance on this authorization or other law allows the Recipient to contest a claim under the policy or to contest the policy itself, by sending a written request to: American General Life Companies Service Center, P. O. Box 4373, Houston, TX 77210-4373. I understand that my revocation of this authorization will not affect uses and disclosures of my health information by the Recipient for purposes of underwriting, claims administration and other matters associated with my application for insurance coverage and the administration of any policy issued as a result of that application.

I understand that the signing of this authorization is voluntary; however, if I do not sign the authorization, the Companies may not be able to obtain the medical information necessary to consider my application.

This authorization will be valid for 24 months. A copy of this authorization will be as valid as the original. I understand that I am entitled to receive a copy of this authorization.

________________________________________________________________________________	__________________________________
Signature of Proposed Insured or	Date
Proposed Insured's Personal Representative
________________________________________________________________________________
Description of Authority of Personal Representative
(if applicable)

AGLC100633 Rev0113