Life Insurance Application

LIA-CA (11-10)
LIA-CA (11-10)
INSTRUCTIONS
As the Agent, you are responsible for completing the necessary forms required to process and underwrite this application. All forms
must be completed in full and must be legible. Please follow these instructions carefully.
DO
Print application in black ink.
Verify identification of Proposed Insured.
Obtain all of the necessary signatures.
Give the Notice to Proposed Insured to your client.
Have the Proposed Insured/Owner initial all changes. The Proposed Insured must initial all changes to questions involving
insurability. Change an answer by putting a line through the incorrect answer and inserting the correct information.
Complete Part 2, Medical History, if the Proposed Insured is to be considered without paramedical exam, if an exam on
another company’s form is being used or if an abbreviated exam will be done.
Complete section K, Part 1 on all business cases and if required on non-business cases.
Complete and obtain signature on Consent for HIV Testing Form for each Proposed Insured, if required in your state.
If you accept payment with the application:
Complete the Temporary Insurance Application section of the Temporary Insurance Application and Agreement (TIAA),
making sure that all questions are answered. If any are answered Yes, do not accept money.
Remit an amount equal to the first modal premium.
Explain the terms and conditions of the TIAA to the Owner and Proposed Insured and have them sign it.
Complete and sign the Licensed Insurance Agent’s Statement on the TIAA.
Send the TIAA with the application, give the Owner a copy.
All checks collected must be made payable to Banner Life Insurance Company.
If applicable, complete and obtain signature(s) on the Payment Options form.
Complete and sign the Agent’s Report on page 12. Please be sure to enter all agent information and your Banner agent
number.
DO NOT
Do not accept money on applications now applied for or pending with Banner Life Insurance Company totaling over
$1,000,000.
Do not accept any payment if any question on the Temporary Insurance Application and Agreement is answered Yes or left
blank.
Do not accept cash or cash equivalents (money order, cashiers check) or “starter” checks.
Do not accept money if the Proposed Insured is over age nearest 70.
Do not use pencil or correction fluid.
LIFE INSURANCE APPLICATION
Banner Life Insurance Company
3275 Bennett Creek Avenue
Frederick, Maryland 21704
(800) 638-8428
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Life Insurance Application PDF

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