APPLICANT’S STATEMENT: I understand that the broker receiving this application does not have authority to modify or waive any portion of this application or any coverage, conditions or restrictions contained in the insurance policy applied for and that all information requested in the application must be set forth in writing on the application. I further understand that this application will become part of the insurance policy to be issued and that the insurer will be utilizing the information contained in this application to determine whether or not to issue the insurance policy applied for.
I understand that the broker taking this application from me is the representative of and is acting on my behalf and not the administrator nor the insurance company that is offering this insurance. Neither the administrator nor the company that is offering this insurance can be held liable for any circumstance if the broker, who is taking this application, fails now or in the future to transmit or communicate any documentation or funds from the administrator to me and/or any documentation or funds from me to the administrator.
By checking this box, I understand and agree to the above.
MEDICAL AUTHORIZATION:I hereby authorize any physician, medical practitioner, hospital, clinic, other medical or medically related facility, the Medical In-formation Bureau, Inc. (MIB, Inc.) or other organization, consumer reporting agency, insurance or reinsuring company, institution or person having any record or knowledge of me or my health, including any member of my family, to give to the insurer offering the insurance, any reinsurer or its legal representative any and all such information. The nature of the information authorized to be disclosed includes information about all medical evaluation, care, treatment, diagnosis or consultation provided to the undersigned insured, or my dependents. I understand the information obtained by use of this authorization will be used by the insurer offering the insurance, and its reinsurers to determine eligibility.
I direct that a copy of this authorization shall be given the same force and effect as the original. This authorization shall remain valid as long as this policy is in force.
PRE-EXISTING CONDITIONS: means any condition or consequence related to a medical condition, Sickness or Accident for which medical advice, consultation, diagnosis, care or treatment was received, or medications prescribed or taken, within the seven (7) years prior to the Effective Date of this Policy or its Reinstatement or; or (2) a condition that would have caused a prudent person to seek medical advice, consultation, diagnosis, care or treatment prior to the Individual Effective Date of this Policy; or 3) a condition for which medical advice, consultation, diagnosis, care or treatment or any obvious symptom thereof which, if presented to a Physician would have resulted in an attempt to diagnose the condition producing the symptoms prior to the Effective Date of this Policy; or 4) any Covered Charges or Covered Services for Pregnancy within twelve (12) months after the Effective Date of Coverage under this Policy.