Enrollment Form For Group Life Insurance
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1
2ENROLLMENT FORM FOR GROUP LIFE INSURANCE
2735FE(v5)-WA 06/11 NGL AssetGuard
Mail Policy To:
Agent/Producer
National Guardian Life Insurance Company (NGL) - Phone 800.762.9883 - Fax 866.228.9927
Owner (Default)
Two East Gilman Street - PO Box 1191 - Madison WI 53701-1191
PROPOSED INSURED
MALE
FEMALE
__________________________ ____ __________________________ __________________________ __________________________ _____ _______________________
First Name
MI
Last Name
Phone Number
Social Security Number
Age
Date of Birth
OWNER - Complete only if other than Insured
__________________________________________ ___ ____________________________________ __________________________________ _______________________
First Name
MI
Last Name
Social Security Number
Relationship to Insured
OWNER MAILING ADDRESS
___________________________________________________ __________________________ _________ _______________ ______________________________________
Street Address
City
State
Zip
Email Address
Face Amount $ ____________ Premium $ ____________
PAYMENT PLAN
Single Pay Life
PLAN
A
B
C
D
E
F
G
H
*Complete the premium
PAYMENT MODE
EFT*
MC/VISA*
withdrawal authorization
STATEMENT OF HEALTH (To be completed by Proposed Insured): Are you currently on oxygen, hospitalized, receiving hospice care,
or residing in a nursing home, long term or residential care facility, or group home; or during the past two years have you been advised
by a medical professional to have any surgical procedure that has not been performed; or have you been treated or are you being treated
(including medication) by a medical professional for any of the following diseases or disorders:
YES
NO
Congestive Heart Failure
Immune System Disorder
Chronic Obstructive Pulmonary (lung) Disease
Amputation (caused by disease)
Heart Disease
Cirrhosis of the Liver
Emphysema
Alzheimer’ s /Dementia
Stroke
Drug or Alcohol Dependency
Amyotrophic Lateral Sclerosis (Lou Gehrig’ s Disease)
Cancer (other than skin)
Kidney failure (including dialysis)
Diabetic Coma/Insulin Shock
BENEFICIARY INFORMATION
______________________________________________________________________________________________________________________________________________
Name of Primary Beneficiary, Estate of Insured, or NGL Trust
APPLICANT REPLACEMENT - Will the insurance applied for replace or change any insurance or annuity now or recently in force?
YES
NO
If “Yes”, complete required replacement form(s).
AGENT/PRODUCER REPLACEMENT - Will the insurance applied for replace or change any insurance or annuity now
YES
NO
or recently in force?
APPLICANT SIGNATURES
To the best of my knowledge and belief, the above information is true and complete. I understand that no insurance will be effective until this
form is approved and the Policy is issued while the Insured is living. I acknowledge that the Policy applied for provides funds at the time of death
which may be used for the purchase of funeral services and merchandise, but does not provide specific funeral services and merchandise. It is
not an agreement with a funeral establishment. I understand that any information provided regarding the cost of funeral services was provided
as general consumer information only. No representations were made that specific merchandise and/or service have been purchased or will be
provided at the time of death. If I am the Owner for insurance on the life of the Proposed Insured, I certify that I have an insurable interest in his or
her life. I acknowledge that I have read the fraud warning statement on the last page of this form.
________________________________________________________________________________________________
__________________________________________
Signed At
State
__________________________________________________ __________________
_______________________________________________ ___________________
Signature of Proposed Insured
Date
Signature of Owner (Required if other than Insured)
Date
AGENT/PRODUCER’S STATEMENT I certify that any information recorded by me on this form is true and accurate to the best of my
knowledge.
Check here for Agent/
_____________________________________ _____________________________________________ _________________________
Producer Split and see
Agent/Producer Signature
Agent/Producer Name Printed
NGL Agent/Producer #
last page.
2735FE-WA 06/11
1st Copy- Company 2nd Copy- Agent/Producer
3rd Copy- Purchaser
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