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  Accidental Death Benefit
- No Medical Exam, No Health Questions

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Fidelity Life’s Accidental Death Benefit policy is available from ages 20 through 65, with coverage limits between $50,000 and $500,000. The policy is underwritten on a guaranteed issue basis—there are no medical questions on the application. Most applications are approved within 24 hours. Fidelity Life’s Accidental Death Benefit policy is available from ages 20 through 65, with coverage limits between $50,000 and $500,000.  

Start the APPLICATION process now by answering the questions below. Your information will be transferred to the application which will be emailed to you for your final review and approval by e-signature.
For any Assistance please Call (800) 393-3592.
For your convenience we can do the application by phone. For assistance in finding a life insurance solution with FidelityLife or other Carriers and plans please Call (800) 393-3592.
The policy is underwritten on a guaranteed issue basis—there are no medical questions on the application. Most applcations are approved within 24 hours. Applicants must be a U.S. Citizen or have permanent resident status (green card).

 
PROPOSED INSURED  
Full Legal Name of the Proposed Insured*: 
First | M. | Last
Gender *: 
Date of Birth *: 
/ /
Age: 
Place of Birth: 
Social Security Number: 
Legal Residence Address: 
Years at this Address: 
City*: 
State: 
Zip: 
Day Phone*: 
- -
Evening Phone: 
- -
Best Time to Call (If Needed): 
 - 
Email*: 
Are you a U.S. Citizen or do you have  Permanent  Resident Status (a Green Card)?: 
Occupation: 
Employer or Business Name: 
COVERAGE  
Choose A Product*: 
Face Amount*: 

Issue Limits:Age 20-65, $50,000 to $500,000 | The policy pays full benefits until age 70, at
which time benefits reduce by 50%. Benefits then remain level at this reduced amount until the policy expires at age 80.

Family Accidental Death Benefit Rider: 
Inflation Benefit Rider: 
Increases the death benefit by an amount equal to 5% of the initial policy death benefit each year between policy years 2 and 6. After year 6 the death benefit remains level throughout the life of the policy.
Mode of Payment: 
Billing Method: 
   
OTHER COVERAGE
(Please list the following)
Do you have any existing life insurance in force or is any application for life insurance, or reinstatement, now pending?
1. Other Life Insurance - Name of Company, Face  Amount $ , Year Issued: 
   Replace:
2. Other Life Insurance - Name of Company, Face  Amount $ , Year Issued: 
   Replace:
3. Other Life Insurance - Name of Company, Face  Amount $ , Year Issued: 
   Replace:
4. Other Life Insurance - Name of Company, Face  Amount $ , Year Issued: 
   Replace:
If this policy is issued: 
Will any other existing life insurance or annuity be cancelled, terminated, lapsed or not renewed?
Owner and Beneficiary  
Policyowner (The Policyowner will be the Proposed  Insured unless otherwise indicated): 
 Policyowner
 (Not Proposed Insured):

 Relationship to Insured:
 SSN/TaxID:
Billing Address: 
Secondary Addressee (Optional - This person will  receive copies of your overdue premium and lapse  notices): 
 Name:
 Mailing Address:
   
Primary Beneficiary (Complex beneficiary  designatins should be dealt within the context of a  Will): 
1. Primary Beneficiary
 Full Name:
Percentage %: (1-100%)
 Relationship to Insured:   SSN/TaxID:
  2. Primary Beneficiary
 Full Name:
Percentage %: (1-100%)
 Relationship to Insured:   SSN/TaxID:
  3. Primary Beneficiary
 Full Name:
Percentage %: (1-100%)
 Relationship to Insured:   SSN/TaxID:
  4. Primary Beneficiary
 Full Name:
Percentage %: (1-100%)
 Relationship to Insured:   SSN/TaxID:
   
Contingent Beneficiary: 
1. Contingent Beneficiary
 Full Name:
Percentage %: (1-100%)
 Relationship to Insured:   SSN/TaxID:
  2. Contingent Beneficiary
 Full Name:
Percentage %: (1-100%)
 Relationship to Insured:   SSN/TaxID:
  3. Contingent Beneficiary
 Full Name:
Percentage %: (1-100%)
 Relationship to Insured:   SSN/TaxID:
  4. Contingent Beneficiary
 Full Name:
Percentage %: (1-100%)
 Relationship to Insured:   SSN/TaxID:
 
Preauthorized Payment Authorization Method  
I request that my premium payments be debited  from my bank account as shown: 
 PRE-AUTHORIZED CHECK (EFT):   Name Of Bank:     Routing#:  Account#:  

(As a convenience to me, I authorize Fidelity Life Association, A Legal Reserve Life Insurance Company (“Fidelity Life”) to make electronic debits or other forms of preauthorized withdrawals from my financial institution as indicated below. I understand that if a debit or withdrawal is
not honored by the financial institution, Fidelity Life will consider the premium unpaid. Any debit or withdrawal returned due to insufficient funds may be redeposited by Fidelity Life. This authorization will remain in effect until written notice by the depositor/card holder is received
by Fidelity Life. I further agree that if any such debit or withdrawal is not honored, whether with or without cause, Fidelity Life shall be under no liability whatsoever even though such dishonor results in the lapse of insurance, in accordance with the grace period.)
 
I request that my premium payments be debited  from the credit card shown below: 
 PRE-AUTHORIZED CREDIT CARD:     Credit Card: 
 
Card#:  Expiration Date: / /
   

Important (Please Read)

This information will be transferred to the application which will be emailed to you for your final review and approval by e-signature, before sending to Fidelity Life.
If you need assistance during the information gathering process above, please Call (800) 393-3592, and an authorized agent from our company will return your call.

Thank you.
Sincerely, DelPacific Insurance Services

I declare that each answer and statements given to the questions contained in this application is complete and true to the best of my knowledge and belief. I understand and agree that Fidelity Life will rely on these answers, and the answers and statements I may give in any other form taken as a part of this application as representations and not warranties and that no such statement shall void the policy unless it is contained in a written application and a copy of such application shall be endorsed upon or attached to the policy when issued. I also understand that Fidelity Life reserves the right to accept or deny this application after taking into account whatever information may be available to it, including availability as to coverage by its reinsurers. The coverage will be effective on its date of issue if the: (a) health; (b) avocations; (c) occupation; and (d) any other condition relating to the Proposed Insured are as described in the application. The effective date is the Policy Date shown on page 3.
I, the Proposed Insured, authorize any physician, medical practitioner, hospital, clinic, pharmacy, pharmacy benefit manager or other medical or medically related facility, insurance or reinsurance company, the Medical Information Bureau (MIB), consumer reporting agency or employer to give to Fidelity Life any information they might have regarding the diagnosis, treatment, prescription and prognosis of any physical or mental condition, my driving record, avocations, credit history, insurance history, occupation, character and hobbies, as applicable. To facilitate the rapid transmission of such information, I authorize all said sources, except the MIB, to give such records or knowledge to any agency employed by Fidelity Life to collect and transmit such information. I agree that this authorization shall remain in effect for two years (24 months) from the date that it is signed and that a copy of it shall be as valid as the original. I understand that the information obtained with this authorization shall be used to evaluate my application for insurance. I understand that I, or someone I authorize to act on my behalf, may obtain a copy of this authorization. I also understand that I have the right to revoke this authorization at any time. All or part of such information may be disclosed to a physician of my choosing, my insurance agent, the Medical Information Bureau (MIB), to other persons or organizations performing business or legal services in connection with this application, including reinsuring companies and
as may be required by law.
   
* Please fill in where indicated.
   
   

 


| Fax: (800) 590-4049 | Email: web@delpacificis.com |
Mailing Addr: P.O. Box 892919, Temecula, CA. 92589 | Life | Health | Dental | Disability | Critical Illness | Long Term Care | Medicare HMO Plans |

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