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Application

Application for Individual Life Insurance

Whole Life Insurance Policy: Form ICC14-L-0020
Term Life Insurance Policy: Form ICC16-L-0023
PHILADELPHIA AMERICAN LIFE INSURANCE COMPANY • P.O. BOX 4884, HOUSTON, TX 77210-4884 • 281-368-7200 • 1-877-368-4692
Coverage Selection
Whole Life Insurance Primary Applicant Spouse/Legal Domestic Partner Child 1 Child 2 Child 3 Child 4
Amount of Insurance $ $ $ $ $ $
Children Term Rider (ICC14-R-0006) $ $  
Premium Amount $ $ $ $ $ $
Term Life Insurance Primary Applicant Spouse/Legal Domestic Partner  
Amount of Insurance $ $  
Children Term Rider (ICC14-R-0006) $ $ Total Amount Paid With Application  $
Premium Amount $ $  
Applicant(s) Information
Primary Applicant Name (First/Middle/Last):
First Middle Last
Social Security #:
Birthdate:
  Male Female
Daytime Phone:
E-mail Address:
State or Country of Birth:
Address:
 City:
 State:
 Zip Code:
Business Name and Address:
 City:
 State:
 Zip Code:
Business Phone:
 Hire Date:
 Annual Salary:
 Occupation:
During the past 3 months, except for minor illness of 1 week or less or pregnancy, has any illness, injury or health related problem prohibited
the Primary Applicant from working full time at his/her regular occupation or performing the normal activities of a person of the same age?		  Yes No
Spouse/Legal Domestic Partner Name (First/Middle/Last):
 Social Security #:
 Birthdate:
  Male Female
Child 1 Name (First/Middle/Last):
 Social Security #:
 Birthdate:
  Male Female
Child 2 Name (First/Middle/Last):
 Social Security #:
 Birthdate:
  Male Female
Child 3 Name (First/Middle/Last):
 Social Security #:
 Birthdate:
  Male Female
Child 4 Name (First/Middle/Last):
 Social Security #:
 Birthdate:
  Male Female
Owner (If other than Primary Applicant):
 Social Security #:
 Birthdate:
 Relationship:
Address:
 City:
 State:
 Zip Code:
Tobacco Usage Question (Does not apply to children ages 15 and below)
Has any applicant used tobacco in any form within the past 24 months?
Primary Applicant Spouse/Legal
Domestic Partner		 Child 1 Child 2 Child 3 Child 4
 Yes No  Yes No  Yes No  Yes No  Yes No  Yes No
Beneficiary Information (Primary Applicant is beneficiary of Spouse/LDP and Children coverage)
Primary Beneficiary Name:
 Social Security #:
 Relationship:
 Birthdate:
Address:
 City:
 State:
 Zip Code:
Primary Applicant - Contingent Beneficiary:
 Social Security #:
 Relationship:
 Birthdate:
Address:
 City:
 State:
 Zip Code:
Health Question
Primary Applicant Spouse/Legal
Domestic Partner		 Child 1 Child 2 Child 3 Child 4
1. Has any applicant ever been diagnosed or treated (including
prescription medications) by a member
of the medical profession for: Congestive
heart failure, peripheral neuropathy, organ
transplant or organ failure, Alzheimer’s
disease, Parkinson’s disease, ALS (Lou
Gehrig’s disease), Muscular Dystrophy,
Multiple Sclerosis, Acquired Immune
Deficiency Syndrome (AIDS) or AIDS
Related Complex (ARC), or tested positive
for the Human Immunodeficiency Virus
(HIV), Paraplegia or Quadriplegia, Suicide
attempt or Leukemia?		  Yes No  Yes No  Yes No  Yes No  Yes No  Yes No
2. Excluding Human Immunodeficiency
Virus (AIDS virus), in the past 12
months, has any applicant been advised
by a member of the medical profession
to have any diagnostic screening test or
procedures which have not been
performed or for which results have not
been received?		  Yes No  Yes No  Yes No  Yes No  Yes No  Yes No
3. In the past 5 years, has any applicant
been diagnosed, treated (including
prescription medication), tested
positive for, or been given medical
advice by a member of the medical
profession for:		            
a. kidney dialysis, heart attack, stroke or
Transient Ischemic Attack (TIA), aneurysm,
angina pectoris, coronary bypass, or any
heart procedure to improve coronary
circulation including but not limited to
stents, pacemaker, heart valve procedure
or abnormal heart beat?		  Yes No  Yes No  Yes No  Yes No  Yes No  Yes No
b. Cancer (other than basal cell skin
cancer), melanoma or other malignancy,
tumor, hodgkin’s disease, sickle cell or
aplastic anemia or any other blood
disorder?		  Yes No  Yes No  Yes No  Yes No  Yes No  Yes No
c. Chronic Obstructive Pulmonary Disease
(COPD), emphysema or Chronic
Obstructive Lung Disease (COLD) or used
oxygen to assist in breathing or
Tuberculosis?		  Yes No  Yes No  Yes No  Yes No  Yes No  Yes No
d. Epilepsy, convulsions, mental or nervous
disorder including mental retardation or
autism?		  Yes No  Yes No  Yes No  Yes No  Yes No  Yes No
e. Crohn’s Disease or ulcerative colitis,
diabetes, Liver cirrhosis, hepatitis,
systemic lupus erythematosus or
neuropathy?		  Yes No  Yes No  Yes No  Yes No  Yes No  Yes No
Health Question cont.
Primary Applicant Spouse/Legal
Domestic Partner		 Child 1 Child 2 Child 3 Child 4
4.
been diagnosed, treated :		            
a. Used narcotics, barbiturates,
amphetamines, hallucinogens, heroin,
cocaine, or other habit forming drugs,
except as prescribed by a physician?		  Yes No  Yes No  Yes No  Yes No  Yes No  Yes No
b. Sought or received medical treatment or
counseling for, or been advised by a
physician to discontinue, the use of alcohol
or prescribed or non-prescribed drugs? 		 Yes No  Yes No  Yes No  Yes No  Yes No  Yes No
5. In the last 12 months, has any applicant had an application for life insurance rejected?  Yes No  Yes No  Yes No  Yes No  Yes No  Yes No
6. Within the last 3 years, has any
applicant participated in: flying in any
type of aircraft as a student pilot or crew
member; parachute jumping; automobile or
motorcycle racing; hang gliding or scuba
diving to depths of more than 60 feet/18
meters?		  Yes No  Yes No  Yes No  Yes No  Yes No  Yes No
7. Does your weight exceed the
maximum weight on the Maximum
Weight Table below?		  Yes No  Yes No  Yes No  Yes No  Yes No  Yes No
MAXIMUM WEIGHT TABLE
Height 4’11” 5’0” 5’1” 5’2” 5’3” 5’4” 5’5” 5’6” 5’7” 5’8” 5’9” 5’10” 5’11” 6’0” 6’1” 6’2” 6’3” 6’4” 6’5”
Weight (lbs) 200 205 215 220 225 230 235 240 250 255 265 270 280 285 295 305 315 320 335
Name, Address and Phone Number of Physician(s):
Primary Applicant:
Spouse/Legal Domestic Partner:
Child 1:
Child 2:
Child 3:
Child 4:
Other Life Insurance or Annuities
Primary Applicant Spouse/Legal
Domestic Partner		 Child 1 Child 2 Child 3 Child 4
Does any applicant have existing life
insurance or annuity contracts with the
company or any other company?		  Yes No  Yes No  Yes No  Yes No  Yes No  Yes No
Will this coverage replace or change any
life insurance or annuity contract in force
with the company or any other company?		  Yes No  Yes No  Yes No  Yes No  Yes No  Yes No
If “Yes”, please complete information below. Plan Type is: I – individual, B - business, G – group, P - pending
Applicant Name:

 Existing Coverage Insurer’s Name:
 Policy/Certificate #:
 Plan Type:
 Maximum Benefits:
 Termination Date:
Applicant Name:

 Existing Coverage Insurer’s Name:
 Policy/Certificate #:
 Plan Type:
 Maximum Benefits:
 Termination Date:
Applicant Name:

 Existing Coverage Insurer’s Name:
 Policy/Certificate #:
 Plan Type:
 Maximum Benefits:
 Termination Date:
Applicant Name:

 Existing Coverage Insurer’s Name:
 Policy/Certificate #:
 Plan Type:
 Maximum Benefits:
 Termination Date:
Agent Information
To the best of your knowledge, will the insurance applied for replace or change existing insurance?  Yes No If “Yes”, submit complete requirements of the state where the application was signed.
I certify that I have truthfully and accurately recorded the answers provided by the applicant(s) in this application.
Writing agent name: Signature: Date:
Agent Percent License No.
Agent Percent License No.
Premium Information
Whole Life Insurance Automatic Premium Loan:  Yes No
Payment Mode:  Monthly Quarterly Semi-Annual Annual Payment Type:  Monthly Bank Draft Direct Bill List Bill
Payor if other than Payor’s Name Payor’s Address
Primary Applicant: Daytime Phone Relationship
Pre - Authorization ( PAC) Check Payment Plan
Primary Applicant Name (as it appears on bank account)
Account Number
Name of Financial Institution (Bank)
Address of Financial Institution (Bank)
I hereby authorize Philadelphia American Life Insurance Company to initiate debit entries to my account indicated above, and I authorize the Financial
Institution named above to charge the amount of such entries to my account. I further authorize Philadelphia American Life Insurance Company to initiate
credits to my account to correct errors, and Institution to deposit any such corrections to my account.
I hereby authorize Philadelphia American Life Insurance Company to initiate debit entries to my account indicated above, and I authorize the Financial
Institution named above to charge the amount of such entries to my account. I further authorize Philadelphia American Life Insurance Company to initiate
credits to my account to correct errors, and Institution to deposit any such corrections to my account.

Signature
Second Signature for Joint Account
Date
(Attach voided check or deposit slip)
Acknowledgement and Authorizations
I hereby apply to Philadelphia American Life Insurance Company (the Company) for coverage under a Policy to be issued in reliance upon the written answers
to the questions in this Application which I have answered to the best of my knowledge and belief. I understand and agree that (1) the coverage shall not take
effect unless the Application has been accepted and approved in writing by the Company and until the Effective Date of my coverage under the Policy and
(2) my coverage will not become effective until all necessary underwriting information has been received and reviewed by the Home Office and that the
requested Effective Date may be delayed if the Home Office requires additional medical information to process my Application and (3) the agent does not
have the authority to waive a complete answer to any question in the Application, pass on insurability, make or alter any part of the contract, or waive any of
the Company's other rights or requirements. I understand and agree that the falsity of any answer or statement in this Application may bar the right to recover
under the Policy if such answer materially affects the acceptance of the risk or hazard assumed by the Company. The Company may rely upon this Application
and all of the information contained herein.
I hereby authorize and request any physician, hospital, dentist, pharmacy, pharmacy benefit manager, individual, employer, insurance company, law
enforcement agency, governmental agency or other entity to permit bearer or representative of the Company to view, copy, be furnished a copy or be given
details of all record information in connection with any past or present illnesses, financial records, employment records and/or police records. This authorization
is to include, but is not limited to information pertaining to diagnosis, care or treatment for psychiatric disorder, drug and alcohol abuse, treatment or
prescriptions, testing and/or treatment of Human Immunodeficiency Virus (HIV) (AIDS virus) and/or sexually transmitted diseases. Health information obtained
will not be re-disclosed without your authorization unless permitted by law, in which case it may not be protected under federal privacy rules. The results of a
Human Immunodeficiency Virus-related test shall be confidential and we cannot release or disclose this information except in certain circumstances permitted
by law. Any physician, practitioner, hospital, clinic, other medical or medically related facility, the Veterans Administration, my employer or consumer reporting
agency or insurance company who possesses information of care, treatment or advice of me, my family, or our health may furnish such information to the
Company or it’s representative or it’s reinsurers upon presenting this authorization or a photocopy. The Company or its reinsurers may make a brief report
available regarding me or my dependents to other companies to whom I have applied or may apply. I understand that I may revoke this authorization at any
time by writing to the Company and that I or my representative is entitled to receive a copy of this authorization form upon request. This authorization shall
remain in effect for the amount of time, if any, permitted by applicable law in the state where the policy is delivered or issued for delivery.
Temporary Insurance Agreement (TIA)
Subject to the terms of the policy applied for and this TIA, the Company agrees to pay the lesser of the Amount of Insurance applied for or $100,000, upon
receipt of due proof that an applicant died while Temporary Insurance was in effect. I understand and agree that Temporary Insurance will only begin for any
applicant if: (1) I am actively at work on the date of application, the usual number of hours, without limitation; and (2) I have answered “No” to all applicable
health questions in the application. Temporary Insurance coverage is contingent upon the first payroll deduction being made within 60 days from the date of
the application. If a claim is made during the interim coverage period, all policy provisions will apply, including contestability in determining benefit eligibility.
Temporary Insurance ends on the earliest date of the following: (1) the Company sends notice to the applicant at the address shown on the application that
the Company has declined to issue insurance; or (2) 60 days from the date of the application.
If my employer is administering premium payment, I hereby authorize my employer to deduct the required premium from my pay for the coverage applied for
in this application and forward same to the Company.
I acknowledge receipt of the Notice Regarding Replacement form if this is a replacement.
Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

Primary Applicant/Guardian Signature
Signed at (City and State)
Date

Spouse/Legal Domestic Partner Signature
Signed at (City and State)
Date

Witness (Licensed Resident Agent)
Owner, if other than Primary Applicant
Date
P.O. BOX 4884, HOUSTON, TX 77210-4884
Detach this page and leave it with the applicant.
Temporary Insurance Agreement Notice
Subject to the terms of the policy applied for and this TIA, the Company agrees to pay the lesser of the Amount of Insurance applied for or $100,000, upon
receipt of due proof that the applicant died while Temporary Insurance was in effect. It is understood and agreed that Temporary Insurance will only begin for
any applicant if the applicant is actively at work on the date of the application, the usual number of hours, without limitation, and all applicable health questions
in the application have been answered “No”. Temporary Insurance coverage is contingent upon the first payroll deduction being made within 60 days from the
date of the application. If a claim is made during the interim coverage period, all policy provisions will apply, including contestability in determining benefit
eligibility. Temporary Insurance ends on the earliest date of the following: (1) the Company sends notice to the applicant at the address shown on the
application that the Company has declined to issue insurance; or (2) 60 days from the date of the application.
If this application is approved as applied for, the policy will be effective on the date this application is approved by the Company. Otherwise, any insurance
issued other than applied for will be effective upon the delivery and acceptance of the policy.
USA Patriot Act Notice
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions, including insurance
companies, to obtain, verify, and record information that identifies each person who opens an account or applies for insurance using an application. What this
means for you: When you apply for insurance, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We
may also ask to see your driver’s license or other identifying documents.

Speak with a licensed Insurance Broker: (800)-768-5708

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