For Members of
<
>
Please return the form by
<Monthhh DD, YYYY>
<**AUTO0000000**DIGIT0000000000**LINE0000000000**
<John Thomas Benjamin Kolawski-Anderson
123 Main Street
Second Address
Anytown US 12345-6789>
4597
STATEMENT OF BENEFITS
(on back)
Please Apply By:
<Monthhh DD, YYYY>
For Members of
<
>
<WL 0814EXP>
<Dear/Aloha> <John Thomas Benjamin Kolawski-Anderson>,
<You are eligible to apply for $25,000 to <$35,000> of TruStage™ Whole Life
Insurance—from the comfort of your own home. And it only takes a few minutes.>
Since you’re busy, maybe you’ve put off buying life insurance. There’s no need to wait
any longer. This whole life insurance is designed to be within easy reach and affordable
for you.
This important protection is underwritten by CMFG Life Insurance Company and pays
income-tax free cash benefits directly to your family in the event of your death.
Please apply before <your birthday on> <Monthhh DD, YYYY>. The sooner you return
the enclosed form, the sooner you could lock in your rate and have protection for those
near and dear to you.
This could be the life-long protection you need to help feel secure, knowing your
family will have this benefit if they must go on without you. Questions? Call toll-free
<1‑855‑591‑9019>.
<Sincerely/Mahalo>,
<
Frank E. Cain, Director, Licensed Insurance Agent
TruStage Insurance Agency
>
<John
<John
<John
<John
A.
A.
A.
A.
Official
Official
Official
Official
Name 40 Character Max>
Title 40 Character Max>
Title 40 Character Max>
Title 40 Character Max>
P.S. It’s easy to apply and only takes a few minutes. Please respond before <your
birthday on> <Monthhh DD, YYYY>.
A TRUSTED COMPANY
RECOGNIZED FOR ETHICAL PRACTICES
<TUVWXYZ Generic Company Community Federal Credit
Union> has selected TruStage insurance from CMFG Life,
because this company has a long history of serving credit
unions and their members.
TruStage insurance and CMFG Life are proud to be a part of
CUNA Mutual Group, who was named to Ethisphere’s 2014 list
of the World’s Most Ethical Companies. This achievement is
due to the company’s ethical behavior, compliance practices,
and social responsibility. Only 143 companies in the world were
selected for this prestigious honor (ethisphere.com).
For nearly 80 years, CMFG Life has been providing insurance
protection designed to be affordable for credit union members.
Today more than 14 million members have a TruStage policy,
relying on this coverage to help protect their loved ones.
TruStage remains true to its mission of providing quality service
at a good value—exclusively to credit union members.
FINANCIALLY STABLE
CMFG Life remains a financially stable company and
consistently receives an “A” (Excellent) rating from A.M. Best.
“A” is the 3rd highest rating out of a possible 16.
TruStage™ Whole Life Insurance is made available by TruStage Insurance Agency, LLC and underwritten by CMFG
Life Insurance Company, PO Box 61, Waverly IA 50677-0061. The insurance offered is not a deposit, and is not
federally insured, sold or guaranteed by your credit union.
TQW-878980.1-0314-0416
<NWLBDI-0914>
4592
<WL 0814EXP>
STATEMENT OF BENEFITS
TruStage Whole Life Insurance
Prepared For Members of: <TUVWXYZ Generic Company Community Federal Credit Union>
Eligible to Apply: <John Thomas Benjamin Kolawski-Anderson>
Please apply by: <Monthhh DD, YYYY>
3 Lock-in today’s rate. Once approved
and your premium is paid, your rate
and all your benefits never change.
3 In most cases—no physical exam and
no medical tests.*
3 An income-tax free lump sum payment
is made to your loved ones. They can
use this money for anything they need—
house payment, living expenses, college
tuition...
3 Builds cash value over time that you can
borrow and pay back later. Any unpaid
balance, plus interest, is subtracted from
the death benefit.
3 Coverage begins immediately once
accepted and your policy is active.
3 Your spouse can also apply to help your
household have more protection. Please
call for spouse rates. (The definition
of spouse includes a legal partner as
defined by state law.)
It’s easy to apply!
Everything you need is enclosed. To save
you some time, we prefilled your name
and address for you.
*In rare circumstances, a paramedical exam may be
necessary to verify information received during the
underwriting process.
Exclusions: If death results from suicide during the first two years of coverage (one year in ND)
benefits are limited to a return of premiums paid without interest.
THREE KEY REASONS TO APPLY RIGHT NOW
3 This whole life insurance is permanent. The rate you get when your policy is
issued will be locked in for the rest of your life.
3 Your rate will never be lower. Since rates are based partially on age, you could pay
less if you apply <before your birthday> and are approved at your current age.
3 You can easily apply right now. Please complete and return the enclosed
application by <Monthhh DD, YYYY>.
<TUVWXYZ Generic Company Community Federal Credit Union> trusts TruStage to
protect members like you. TruStage is pleased to offer this opportunity to help you
provide for your family.
30-DAY REVIEW PERIOD
Sign up today with confidence. Once approved, your monthly premiums will be deducted
from your account, or billing notices will be sent to you. If you’re not completely satisfied for
any reason, simply return your policy within 30 days. Any premiums paid will be refunded to
you, no questions asked. Guaranteed.
<1-855-591-9019
Mon.–Fri. 7am–9pm, Sat. 8am–4pm CT>
<NWLBD-0914>
4593
SEND NO MONEY
RATES DESIGNED TO BE AFFORDABLE*
<WL 0814EXP>
These rates were designed for credit union members
and have been customized for <John Thomas Benjamin
Kolawski-Anderson>.
<$25,000 Coverage>......................... <$00.00/month>
<$27,000 Coverage>......................... <$00.00/month>
<$30,000 Coverage>......................... <$00.00/month>
<$32,000 Coverage>......................... <$00.00/month>
<$35,000 Coverage>......................... <$00.00/month>
Since rates are primarily based on age <and gender>, it may be in
your best interest to apply <before your next birthday>.
Once approved, we’ll mail your policy to you. Your economical rate
will be automatically deducted from your account, or billing notices
will be sent to you.
<< 1234 1234 12345
*Rates shown for TruStage Whole Life Insurance from CMFG Life reflect
standard non-smoking rates. Your rate and acceptance are subject to
underwriting and may be more than the amount shown. Base policy numbers:
ICC13-A30a-038; A30a-038-2013; ICC13-A30a-038(U).
CU12345678 >
PLEASE REPLY BY:
mmddyyyy MN1234567890123
1234 X >>
<Monthhh DD YYYY>
Application for TruStage Individual Whole Life Insurance
Please print in black ink:
CMFG Life Insurance Company • PO Box 61 • Waverly, IA 50677-0061
Choose your Whole Life Insurance coverage amount below:
<John Thomas Benjamin Kolawski-Anderson
123 Main Street
Second Address
Anytown US 12345-6789>
I wish to apply for the coverage amount below:
If no amount is selected, the lowest amount is assumed.
<
$25,000
$27,000
Primary Phone
Cell Phone
Yes
$32,000
$35,000>
No
Yes
Yes
-
Yes
PLEASE ANSWER THESE QUESTIONS FOR THE APPLICANT:
Yes
Best Time to Call
a.m.
p.m.
-
Secondary Phone
Cell Phone
$30,000
No
Yes
E-mail Address
Yes
Date of Birth (Month, Day, Year)
-
Gender
Male
Driver’s License No.
Are You a
U.S. Citizen?
Yes
No
Yes
-
Occupation
Height
Yes
Yes
State of Issuance
Birth State
Social Security No.
-
Female
Yes
ft.
in.
Weight
lbs.
Your Physician or Clinic (if none, write “none”)
Name
City
State
Yes
Check here only if you do not want the automatic premium loan option.*
Yes
BENEFICIARY INFORMATION:
Beneficiary Name (First, Middle, Last)
Relationship to You
Yes
For additional beneficiaries, please include a separate sheet with
corresponding information, then sign and date.
No 1. Have you, in the past 5 years, had your driver’s license
suspended or revoked, or pled guilty to or been
convicted of 3 or more moving violations?
No 2. Have you ever been convicted of a felony or do you
currently have a felony charge pending?
No 3. Do you plan to travel or reside outside of the US or
Canada within the next 2 years?
No 4. Are you involved in non-commercial flights as a pilot
or crew member, ballooning, hang gliding, sky/scuba
diving, vehicle racing or mountain climbing?
No 5. Have you ever had any insurance declined, postponed,
altered or offered at a higher than standard premium?
No 6. Have you used any form of tobacco, including nicotine
substitutes, in the last 12 months?
No 7. Have you ever used narcotics, barbiturates,
amphetamines, hallucinogens, heroin, cocaine or other
habit forming drugs, except as prescribed by a member
of the medical profession?
No 8. Have you received counseling or medical treatment for,
or been advised by a member of the medical profession
to discontinue the use of alcohol or drugs?
9. Have you ever been treated or diagnosed by a member
of the medical profession as having any of the following
condition(s):
No a. cancer; depression; diabetes; heart condition; high
blood pressure; hepatitis; lupus; paralysis or stroke;
Alzheimer’s disease or dementia; or disorders related to:
intestines; breathing; blood; seizures; brain, mental or
nervous system; muscles, joints or skeletal system; liver;
or kidney?
No b. Acquired Immune Deficiency Syndrome (AIDS), AIDSRelated Complex (ARC), or tested positive for Human
Immunodeficiency Virus (AIDS virus)?
No 10.During the last 5 years, have you been examined,
received treatment or been advised to seek treatment
by a member of the medical profession other than
indicated above? (You may omit treatment for minor
injuries or illnesses (such as colds) which prevent normal
activities for less than 5 days.)
No 11.Are you currently unable to work or attend school
because of any illness or injury?
ICC13-A30f-038(A)
ISWLG14
CONTINUE ON BACK, SIGN AND DATE
<NWLBDCM-0914> 4594
For Credit Union Members Only: This offer is not available to the general public. This
opportunity is being made available to you and your spouse or partner through your
membership at <TUVWXYZ Generic Company Community Federal Credit Union>. The
enclosed materials are personalized for you. Please do not share this “member only”
offer with anyone else.
Please complete and return the enclosed application by <Monthhh DD, YYYY>.
Give dates and details below for any “Yes” answers to questions 1-11 on the previous page.
If more space is needed, attach a signed & dated separate sheet.
Dates
Details of Treatment
Name & Address of Medical
Details or Reasons
or Follow-Up
Professional, Clinic or Hospital
Began
Ended
Question
Number
EXISTING COVERAGE & REPLACEMENT QUESTIONS:
Yes
No 1.Do you have any existing life insurance policies or annuity contracts with our company or any other company?
If yes, please list below. Use additional sheet if necessary then, sign and date.
Name of Company & Policy Number
Coverage Amount
Coverage Type
Yes
No 2.Will the coverage applied for replace, discontinue, or change any existing life coverage or annuities in this or any other company?
If yes, please list below. Use additional sheet if necessary then, sign and date.
Name of Company & Policy Number
u Automatic Payment Authorization: I authorize CMFG Life
Insurance Company to deduct monthly premiums from my credit union
Savings Account for the life coverage applied for on this application. This
authorization will remain in effect until revoked by me in writing or by phone.
You will be notified in writing before the first deduction occurs.
Agreement: All my statements and answers are true to the best of my
knowledge and belief. This application and any supplemental application(s)
will be the basis of any insurance issued. I understand that: (1) benefits may
be denied during the first 2 years from the effective date if I fail to give true
and complete answers in this application, as described in the incontestability
provision of the policy; and (2) this insurance becomes effective only if: a.)
my application is approved and a policy issued; b.) my first full premium due
is received while I am alive and within 21 days of my policy’s issue date; and
c.) the answers to questions concerning my insurability are as stated in this
application.
I authorize any health care providers, pharmacy benefit manager or other
pharmaceutical firm, insurance companies, MIB, Inc. (MIB), consumer
reporting agency, the Department of Motor Vehicles, financial institution,
or employer having information about my physical or mental condition,
prescription drug records, financial status, employment status, or other
relevant information about me, to give all information (except psychiatric
treatment notes) to CMFG Life Insurance Company (“Company”) or its
reinsurers to determine eligibility for insurance or benefits. Information
obtained will be released only to reinsurers, MIB, persons performing
business duties as delegated or contracted for by the Company related to
my application and subsequent insurance-related functions, as permitted
or required by law, or as I further authorize. The health information shared
for these purposes is not subject to federal health information privacy laws;
however state privacy laws do apply.
I authorize the Company, or its reinsurers, to make a brief report of my
personal health information to MIB. I agree this authorization is valid
for 24 months, a copy is as valid as the original, and I or my authorized
representative can receive a copy upon request. For purposes of collecting
information in connection with a claim for benefits, this Authorization is
valid for the duration of the claim. I understand that: (1) I can revoke this
Coverage Amount
Coverage Type
authorization at any time by written request to the Company; (2) revocation
of this authorization will not affect any prior action taken by the Company in
reliance upon this authorization; and (3) failure to sign, or revocation of this
authorization may impair the Company’s ability to evaluate claims or process
applications and may be a basis for denying this application or a claim for
benefits. The Notice to Applicant has been received by me.
Any person who knowingly presents a false or fraudulent
claim for payment of a loss or benefit, or knowingly
presents false information in an application for insurance
may be guilty of a crime and subject to fines and
confinement in prison, and denial of insurance benefits,
depending on state law.
Applicant’s Signature
Date Signed
ICC13-A30f-038(A)
In order to qualify for this coverage, applicants may be required to undergo a paramedical examination and blood/urine testing which will include testing for
the presence of antibodies to the AIDS virus. Applicants will receive additional information and be required to authorize the test(s) to be performed. Based on
your health and other factors affecting your insurability, you may be offered a higher premium rate or you may be denied coverage. *The automatic premium
loan option allows you to borrow against any accumulated cash value from your policy to pay a premium and help prevent a lapse in your policy. This option
is free, and we suggest that you keep this feature. Your credit union enables this insurance program to be offered and is entitled to compensation from
TruStage. The insurance is not a deposit and is not federally insured, sold or guaranteed by your credit union. To stop receiving offers from TruStage, please
call 1-888-787-8243.
<A>
<NWLBDCM-0914> 4595
NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES
RUSH TO:
MARSHA SWANSON
BUSINESS REPLY MAIL
FIRST-CLASS MAIL
PERMIT NO. 21
WAVERLY IA
POSTAGE WILL BE PAID BY ADDRESSEE
CREDIT UNION MEMBER SERVICES
P O BOX 101
WAVERLY IA 50677-9943
1
THREE EASY STEPS:
2
Complete enclosed
application.
Insert in this
postage-paid envelope.
3
Drop in the mail.
Please remember to sign and date your application. You’ll be hearing from us soon.
4598
CMFG Life Insurance Company
P.O. Box 61 | Waverly IA 50677-0061 | Phone: 1-800-779-5433
THIS NOTICE IS TO BE READ BY THE APPLICANT FOR INSURANCE
IMPORTANT
NOTICE TO APPLICANT: Your Privacy is Protected
For residents in all states except NM and VA: In order to evaluate your application for insurance, CMFG Life Insurance Company or its
reinsurers may ask for medical or other personal information about you and any other person to be insured from medical professionals, or
MIB, Inc. (MIB). Residents of VA: In order to evaluate your application for insurance, personal information may be collected from persons other
than an individual proposed for coverage. CMFG Life Insurance Company or its reinsurers may ask for medical or other personal information
about you and any other person to be insured from medical professionals, or MIB, Inc. (MIB).
Information we collect about you will not be given to anyone without your consent, except when necessary to conduct our business. A brief
report may be made to MIB, a non-profit membership organization of life insurance companies, which operates an information exchange on
behalf of its members. If you apply to another MIB member company for life or health insurance, or a claim is submitted to such a company,
MIB, will, upon request, supply such company with information in its file. CMFG Life Insurance Company or its reinsurers may also release
information in its file to other life insurance companies to whom you may apply for insurance, or to affiliated companies, or to whom a claim
for benefits may be submitted.
If you ask, MIB will arrange disclosure of any information it may have in your file. If you question the accuracy of information in the file, you
may contact MIB and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address
of MIB’s information office is 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734, telephone number 866-692-6901 (TTY 866-3463642). Information for consumers about MIB may be obtained on its website at www.mib.com.
Also as a part of our normal procedure for processing your application, an investigative consumer report or other consumer report may be
prepared. In an investigative consumer report, information is obtained through personal interviews with your neighbors, friends, or others
with whom you are acquainted. This inquiry, if obtained, typically includes information as to your character, general reputation, and mode of
living, except as may be related directly or indirectly to your sexual orientation. If you ask, you may be interviewed by the agency preparing
your report and receive a written copy of this report.
Information you give to the agency will be included in the report sent to us.
Residents of NM: In the course of collecting information we may receive confidential abuse information. You have the right to access and
correct all such information that we may receive. If you have been a victim of domestic abuse and desire additional confidentiality regarding
your location, you may designate yourself as a protected person by writing to us at the address listed below. We are prohibited by law from
using your confidential abuse status as basis for denying coverage, refusing to issue, renew, or reissue coverage, or cancelling or otherwise
terminating, restricting or excluding coverage or benefits, or charging a higher premium for your coverage. If you wish to receive additional
information regarding the nature and scope of the investigation, or detailed information regarding our confidential abuse information
practices, you may submit a written request to our Chief Underwriter at CMFG Life Insurance Company, P.O. Box 61, Waverly, IA 50677-0061.
You also have the right to receive a detailed notice regarding our insurance information practices which will include a summary of your rights
to access and correct all information that we may receive.
Residents of VA: You may make a written request to the Chief Underwriter of CMFG Life Insurance Company, P.O. Box 61, Waverly, IA 506770061 for additional information about the nature and scope of the investigative consumer report.
Residents in states except NM and VA: You may make a written request to the Chief Underwriter of CMFG Life Insurance Company, P.O. Box
61, Waverly, IA 50677-0061, within a reasonable period of time for additional information about the nature and scope of the investigative
consumer report. Residents of VA: You may make a written request to the Chief Underwriter of CMFG Life Insurance Company, P.O. Box 61,
Waverly, IA 50677-0061 for additional information about the nature and scope of the investigative consumer report. You also have the right
to receive a detailed notice regarding our insurance information practices which will include a summary of your rights to access and correct
all information that we may receive.
Through these inquiries we seek to offer you coverage at the lowest possible cost.
THIS NOTICE IS TO BE READ BY THE APPLICANT FOR INSURANCE
CU-MIB-1107; CU-MIB-1107(NM)
What’s not covered
This whole life insurance has only one standard exclusion. Suicide is not covered during the first two years your coverage is in force. (In
North Dakota, suicide is not covered during the first year your coverage is in force.) In such cases, benefits will be limited to a return of
premiums paid without interest.
Automatic Premium Loan Provision: Allows you to borrow against any accumulated cash value from your policy to pay a premium and help
prevent a lapse in your policy. This option is free, and we suggest that you keep this feature.
For CA, FL, and VT residents:
SECONDARY ADDRESSEE: You may name a person as Secondary Addressee in the spaces provided on the application. A Secondary
Addressee is not a beneficiary. If you choose to complete the Secondary Addressee information on the application, that person would also
receive notice of lapsed coverage in the event your premiums are not paid (residents of CA: and you are age 64 or older). You are not
required to complete this section of the application. Completing the Secondary Addressee information is optional. If you choose to designate a
Secondary Addressee in the future, or change the person you designated, you may do so at any time by writing CMFG Life Insurance Company.
NOTICE TO APPLICANT: YOUR PRIVACY IS PROTECTED. In order to evaluate your application for insurance, CMFG Life Insurance Company
may ask you to complete questions on an application. Through these questions you will provide us with medical or other personal information
about yourself and any other person to be insured. As part of our normal procedure we may also contact you, your spouse or other insured
family members to ask additional clarifying questions. This additional information will help us better understand the responses you have
provided on your application. Medical information we collect about you will not be used or released for any purpose except as authorized
by you, to underwrite insurance; to administer your policy; investigate and report fraud; or as required by law. Non-medical information may
be disclosed when necessary to administer products and services we provide or as required by law. In order to provide you with information
regarding other financial products or services, we may also disclose some portion of the non-medical information we collect to our affiliated
companies, to non-affiliated third parties with which we have joint marketing agreements or as permitted by law. You have the right to
receive a detailed notice regarding our insurance information practices which will include a summary of your rights to access and correct all
information which we may have collected. Requests should be made in writing to the Chief Underwriter of CMFG Life Insurance Company,
Administrative Office, P.O. Box 61, Waverly, IA 50677-0061. Through the collection and use of this information we seek to offer you coverage
at the lowest possible cost.
CU-SINOTICE-2004
THIS NOTICE IS TO BE READ BY THE APPLICANT FOR INSURANCE. For GA residents: CMFG Life Insurance Company • P.O. Box 61 • Waverly IA 50677-0061 • Phone: 1-800-779-5433
REPLACING YOUR LIFE INSURANCE POLICY? Are you thinking about buying a new policy and discontinuing or changing an existing
policy? If you are, your decision could be a good one ­— or a mistake. You will not know for sure unless you make a careful comparison of
your existing policy and the proposed policy. Make sure you understand the facts. Below you will find a check list of some of the items you
should consider in making your decision. TAKE TIME TO READ IT.
Do not let one agent or insurer prevent you from obtaining information from another agent or insurer which may be to your advantage. Hear
both sides before you decide. This way you can be sure you are making a decision that is in your best interest.
We are required to notify your existing company that you may be replacing their policy.
ITEMS TO CONSIDER
1.If the policy coverages are basically similar, premiums for a new policy may be higher because rates increase as your age increases.
2.Cash values and dividends, if any, may grow slower under a new policy initially because of the initial costs of issuing a policy.
3.Your present insurance company may be able to make a change on terms which may be more favorable than if you replace existing
insurance with new insurance.
4.If you borrow against an existing policy to pay premiums on a new policy, death benefits payable under your existing policy will be
reduced by the amount of any unpaid loan, including unpaid interest.
5.Current interest rates are not guaranteed. Guaranteed interest rates are usually considerably lower than current rates. What rates are
guaranteed?
6.Are premiums guaranteed or subject to change — up or down?
7.Participating policies pay dividends that may materially reduce the cost of insurance over the life of the contract. Dividends, however, are
not guaranteed.
8.CAUTION, you are urged not to take action to terminate, assign, or alter your existing life insurance coverage until after you have been
issued the new policy, examined it and have found it to be acceptable to you.
And, REMEMBER, you have thirty (30) days following receipt of any life insurance policy to examine its contents. If you are not satisfied with
it for any reason, you have the right to return it to the insurer at its home or branch office or to the agent through whom it was purchased,
for a full refund of premium.
1161-2213I/GA(1206)
Your credit union enables this insurance program to be offered and is entitled to compensation from TruStage Insurance Agency, LLC,
P.O. Box 61, Waverly IA 50677-0061. To stop receiving offers from TruStage, please call 1-888-787-8243. Base Form Numbers: ICC13A30a-038; A30a-038-2013; ICC13-A30a-038(U).
4596