Agreement: I represent
federal privacy rules. I authorize the Company, or its reinsurers, to make a brief report of my personal health information to
I have read this Authorization and understand that I may receive a copy upon request. I understand and agree that this Authorization shall be valid for
two years from the date signed below. A copy of this Authorization is as valid as the original. I may revoke this Authorization at any time by providing
written notification of its termination
Fraud Notice: 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.
I verify, when completing electronically, the unique identifier used to sign the application is mine and I am signing the application electronically.
Life Insurance, Critical Illness Insurance, Nursing Home Insurance, Medicare Supplement,
Disability Insurance, Estate Planning, Health Insurance,
Group Insurance, Mortgage Senior, Americo Life,
Final Expense, Permanent, Annuity, Index, Am Best A Rating