Page 1 - PDF document created by PDFfiller

Regular Mail:
United Home Life Insurance Company P.O. Box 7192
Indianapolis, IN 46207-7192
FAX Number: 317-692-7711 Telephone: 800-428-3001
________ # pages including cover Fax only once.
Overnight Mail:
(FedEx or UPS Recommended)
United Home Life Insurance Company 225 South East St.
Indianapolis, IN 46202
Agent Name: _
__
__
___
__
__
Verified by PDFfiller
02/26/2017
TERM LIFE
__________________________ Agent #: _L_0_00_12_3_4_5_6_______________________ Nate Auffort
_
_
_
_
Agent Phone: _(5_5_5_) _5_55_-_5_5_5_5____________________________ Agent Fax: _____________________________ nate.sfg@gmail.com
Agent Email Address: ___________________________________________________________________________ How do you prefer to be notified if we should need any underwriting requirements?
 E-Mail  Fax
Proposed Insured’s Name: _____________________________________________________________________
John D. Smith
Do you personally know the Proposed Insured?  Yes  No
Have you written insurance on the Proposed Insured in the past three (3) years?  Yes  No
Did you personally see all persons proposed for insurance and personally view a photo ID (driver’s license, passport) of the Owner and/or Proposed Insured?  Yes  No
If No, how was the application taken?
Solicited by:  Mail  Phone  Internet  Fax  Other ________________________________________ (Explain)
Did you identify any unusual behavior or suspicious activity by the Owner or Proposed Insured?  Yes  No
If Yes, please explain. __________________________________________________________________________
___________________________________________________________________________________________
You must provide the Owner and Proposed Insured the attached Notice of Insurance Information Practices before submitting the application.
Special Instructions you want us to know: _______________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
MAIL POLICY TO:  Owner  Agent
Check the box to where you would like the policy sent. We suggest
Always include the cover page for both Term & whole life products with UHL
200-783 9-16 (NV) 1 of 2
agent, and to deliver the policy.