Privacy

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Privacy


Agreement: I represent 

federal privacy rules. I authorize the Company, or its reinsurers, to make a brief report of my personal health information to

MIB.

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.


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Disability Insurance, Estate Planning, Health Insurance,

Group Insurance, Mortgage Senior, Americo Life,

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