Did a TRISTAR agent assist you leading up to your choice to purchase life insurance? If so, please choose their name from the list below.

Applicant’s Statement

I understand the broker, agent or agency receiving this application does not have authority to waive any portion of this application or any coverage, condition or restrictions contained in the insurance policy applied for and all information requested in this application must be set forth in writing on the application. I further understand this application will become part of the insurance policy to be issued and the insurer will be utilizing the information contained in this application to determine whether or not to issue the insurance policy applied for.

I understand the broker, agent or agency taking this application from me is an independent representative and is acting on my behalf and not the administrator nor the insurance company offering this insurance. Neither the administrator nor the company offering this insurance can be held liable for any circumstance if the broker, agent or agency taking this application fails now or in the future to transmit or communicate any documentation or funds from the administrator to me and/or any documentation or funds from me to the administrator.

It is understood the insurance applied for shall not become effective until this application is approved and accepted by the insurer, full payment of the first premium is made, and the policy issued subject to all conditions and restrictions contained therein. I understand this policy is not available to permanent resident of the United States or others who reside in the United States. However, if any applicant for coverage, who is accepted and insured by the insurer in the applicant’s country of residence, moves to the United States, the insurer will provide an option to continue insurance coverage.

In order to secure your policy, we are required to collect documents that help us to confirm your identity. If you are able to upload the below requested documents at this time, please do so. If you are not able to upload them right now, don't worry, simply submit the form without the documents attached and an agent will contact you to assist with gathering them.

Please read and sign below the following statements.

Applicant’s Statement

I understand the broker, agent or agency receiving this application does not have authority to modify or waive any portion of this application or any coverage, conditions or restrictions contained in the insurance policy applied for and all the information requested in this application must be set forth in writing on the application. I further understand this application will become part of the insurance policy to be issued and the insurer will be utilizing the information contained in this application to determine whether or not to issue the insurance policy for. I understand the broker, agent or agency taking this application form from me is an independent representative and is acting on my behalf and not the administrator nor the insurance company offering this insurance. Neither the administrator nor the company offering this insurance can be held liable for any circumstances if the broker, agent or agency taking this application fails now or in the future to transmit or communicate any documentation or funds from the administrator to me/or any documentation or funds from me to the administrator. It is understood the insurance applied for shall not become effective until this application is approved and accepted by the insurer, full payment of the first term premium, and the policy issued is subject to all conditions and restrictions contained therein. I understand this policy is not available to permanent resident of the United States or others who reside in the United States. However, if any applicant for coverage, who is accepted and insured by the insurer in the applicant’s country or residence, moves to the United States of America, the insurer will provide an option to continue insurance coverage.

Medical Authorization

I hereby authorize any physician, medical practitioner, hospital, clinic, other medical or medically related facility, the Medical Information Bureau, Inc. (MIB, Inc.) or other organization, consumer reporting agency, insurance or reinsuring company, institution or person having any record or knowledge of me or my health, including any member of my family, to give to the insurer offering the insurance, any reinsurer or its legal representative any and all such information. The nature of the information authorized to be disclosed includes information about all medical evaluation, care, treatment, diagnosis or consultation provided to the undersigned insured, or my dependants. I understand the information obtained by use of this authorization will be used by the insurer offering the insurance, and its reinsurers to determine eligibility and payment of claim benefits under this policy. I direct that a copy of this authorization shall be given the same force and effect as the original. This authorization shall remain valid as long as the policy is in force.