Funeral Insurance Application

Proposed insured(s)
Full Name		 Sex Date of Birth Age Beneficiary(ies)
Full Name		 Relationship to
Proposed Insured		 Insurance
Applied For		 Quarterly Premium Ht Wt
          Total Quarterly Premium:    
               
Policyowner information
Name of Policyowner
Mail Delivery Address
City
State
Zip
Social Security Number
Telephone Number
Occupation
Employer
   
2
Medical Questions Yes No
1. Is each Proposed Insured in good health and free from bodily ailment?
2. Has any Proposed Insured had or been treated for or received medical treatment for any of the following conditions?
  Yes No   Yes No   Yes No   Yes No
Heart Disorder Stroke or Paralysis High Blood Pressure Kidney Disorder
Diabetes Stomach or Digestive Disorder Mental or Nervous Disorder Disease of Nervous System
Cancer or Leukemia Epilepsy or Seizures Hardening of the Arteries Liver Disorder
Alcoholism or Drug Abuse Positive Test for Human Immune Deficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS), or AIDS Related Complex Asthma, Emphysema, or any other Respiratory Disorder Any other disorder or disease
3. Has any Proposed Insured been hospitalized within the past five years?
4. Is any Proposed Insured disabled or been disabled at any time during the past five years?
5. Is any Proposed Insured now receiving treatment or taking medication of any kind?
6. Give complete details of any question answered "Yes" to questions 2 through 5. (IF ANY PROPOSED INSURED HAS BEEN TREATED AT A VETERAN'S ADMINISTRATION HOSPITAL, SSN IS REQUIRED)
Proposed Insured Social Security # Date Condition Medication/Treatment Name/Address/Telephone # of Physician
 
Other Information Yes No
7. Has any Proposed Insured had an application postponed or declined, or been offered a policy other than as applied for by this or any Life, Health, or Accident Insurance Company? If "Yes", give details:

8. Will this insurance replace any existing insurance or annuities? If "Yes", give details:

9. Is the Proposed Insured currently insured or ever been insured with this company? If "Yes", give policy number(s):
 
WARNING: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, presents a false or fraudulent claim for payment of loss or benefit, or knowingly present false information in an application of insurance, is guilty of a crime and may be subject to fines and confinement in prison.
 
I DECLARE that all the answers to the questions above are complete, true, and accurately recorded. I understand and agree that no one has the authority to permit me to withhold information or to answer any question falsely, and that any policy which may be issued by the Company on this application, shall be accepted subject to the terms of the Company. I expressly authorize any physician or hospital to disclose any information acquired by examination or treatment of me; or any member of my family, to the Medical Department of Selected Funeral and Life Insurance Company, Hot Springs, Arkansas. I expressly waive all statutory rights governing such disclosure.