You authorize us to use your Life insurance policy information to pre-fill the form and process and underwrite your request for Income Insurance

I authorize the use of any information contained in my Life insurance policy application and life insurance policy declaration pages for this application for Income Insurance.

 

We rely on the information you provide to underwrite and make coverage decisions.

Any information entered here and transposed on an Application for income Insurance and may be relied upon as the basis for any contract with any Insurer selected (including XXX Company), which may be issued on account of this Application. These statements are to be considered representations and not warranties. I understand any material misstatements or omissions made by me in this form may be used as a basis for rescinding my coverage.

 

There is no guarantee that coverage will be provided.  All benefits presented are estimates subject to change until cover becomes effective.

I understand and agree that no insurance coverage will be in effect until the selected Insurer issues a policy and you pay the Subscription. No producer can waive or change any receipt or policy provision or agree to issue a policy. We will send your information to insurance companies (including XXX Company) who are not obligated to accept your subscription request or issue a policy based on the estimated premiums or benefits we provide you. 

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Authorization to use Health and other information

I authorize any licensed physician, medical practitioner, hospital, clinic, other medical or medically related facility, insurance company, its authorized representatives, Pharmacy Benefit Manager, MIB, Inc. (MIB), IntelliScript, ScriptCheck, Lexis/Nexis or other organization or institution that has any records or knowledge of me or my physical or mental health, including significant history, findings, diagnoses and treatment, including diagnosis and treatment of HIV/AIDS or sexually transmitted diseases, or nonmedical information, such as driving records, any criminal activity or association, hazardous sport or aviation activity, use of alcohol or drugs, and other applications of insurance, to give to the selected insurance company (including Fidelity Security Life Insurance Company), its plan administrators, business associates, or its reinsurers, any such information for use to: 1) underwrite my Application for coverage, make eligibility, risk rating, cover issuance and enrollment determinations; 2) obtain reinsurance; 3) administer claims and determine or fulfill responsibility for coverage a and provision of  benefits; 4) administer coverage; and 5) conduct other legally permissible activities that relate to any coverage I have or have applied for.