The following form is about to take you through several sections, each of which collects specific information needed to assess your eligibility for coverage, administer your policy, and arrange your premium payments, while protecting your privacy in accordance with applicable laws and the Company’s privacy policy.

  1. ​Identity Verification Information – to confirm your identity and ensure that your coverage is correctly matched to you in government and financial records.​

  2. Physical Measurements – to understand basic health indicators (height, weight, sex) that affect eligibility and premium rates under the insurer’s underwriting guidelines.

  3. Beneficiary Selection - to update beneficiary designations, and to ensure that your instructions are clear, current, and can be relied upon by the Company when a claim is made.

  4. Underwriting Medical Questions – to obtain an accurate picture of your health history and lifestyle so the Company can properly evaluate the risk of providing coverage.​

  5. Family Doctor / Clinic / Hospital Details – to allow the Company, if needed, to verify medical information directly with your primary health‑care provider.​

  6. Bank Account Information and Monthly Premium Draft Details – to securely set up and manage preauthorized monthly premium payments from your chosen bank account.​

  7. Authorization for Payments – to record your formal consent for the Company to debit your account for premiums under the terms described in this form.