Cal. Code Regs. tit. 10, § 2249.10
MH1
Insurers Name and Complete Address Called We or Us
SCHEDULE
SC1
Primary Borrower, called you, and Address
SC2
Co-Borrower, also called you
SC3
Policy Number
SC4
Source Code
SC5
Creditor Beneficiary and Insurance Agent's License No.
SC6
Class of Business
SC7
Secondary Beneficiary
SC8
Term of Insurance
SC9
Effective Date
SC10
Original Amount of Life Insurance
SC11
Scheduled Expiration Date
SC12
Monthly Loan Payment
SC13
Monthly Total Disability Benefit
SC14
Decreasing Life: Single ( ) joint ( ) Premium:
SC15
Disability: 30-day Elimination Period Premium:
SC16
Total Premium:SC17 Maximum Monthly Disability Benefit:
SC18
Maximum Amount of Life Insurance:
SC19
Decreasing Single Life Premium:
SC20
Number of Monthly Installments
SC21
First Installment Due Date
SC22
Final Installment Due Date
SC23
Amount of Level Life Insurance:
SC24
Level Life: Single ( ) joint ( ) Premium:
SC25
Level Life Single Premium;
SC26
Group Policy Number
SC27
Certificate Number
SC28
Date of Issue of this Certificate
SC29
Credit Insurance Applied for: ___ Single Life___Joint Life ___30 Day Elimination Disability
SC30
Monthly Premium per $100 of insured debt: Single Life $___ Joint Life $___ Disability $___
SC31
Credit Insurance Applied for:___Single Life ___Joint Life
SC32
Monthly Premium per $100 of insured debt: Single Life $___Joint Life $___
SC33
Credit Insurance Applied for:___Single Life___30 Day Elimination Disability
SC34
Monthly Premium per $100 of insured debt: Single Life $___Disability $___
SC35
Monthly Life Insurance Premium per $100 of insured debt: $___
SC36
Monthly Disability Premium per $100 of insured debt $___
SC37
Maximum Disability Benefit Period
SC 38
Disability, 30-day Elimination Period: Single ( ) Joint ( ) Premium:
SC 39
Credit Insurance Applied for: Life: Single ( ) Joint ( ); 30 Day Elimination Disability: Single ( ) Joint ( )
SC 40
Monthly Premium per $100 of insured debt: Life: Single $___ , Joint $___ ; Disability: Single $___ , Joint $___
Note: Authority cited: Sections 779.21 and 779.27, Insurance Code. Reference: Sections 779.4, 779.6 and 1758.99, Insurance Code.
1. Amendment filed 7-25-83; effective thirtieth day thereafter (Register 83, No. 31).
2. Amendment of section and Note filed 10-2-2006; operative 11-1-2006 (Register 2006, No. 40).