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.

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