Cal. Code Regs. tit. 10, § 2249.11 – Application Blocks.

1. You are not eligible for insurance if you have reached your 65th birthday.
2. You are eligible for disability insurance only if you are working for wages or profit 30 hours a week or more on the Effective Date.
3. Only the Primary Borrower is eligible for disability insurance.
DISABILITY INSURANCE MAY NOT COVER CONDITIONS FOR WHICH YOU HAVE SEEN A DOCTOR OR A CHIROPRACTOR IN THE LAST SIX MONTHS.
(Refer to “Total Disabilities Not Covered” in your certificate for details.)
Date
Primary Borrower
Age
Co-Borrower
Age
AP 2
APPLICATION OF BORROWER
You are applying for credit insurance marked above. Your signature below means that you agree that you are not eligible for insurance if you have reached your 65th birthday.
Date
Primary Borrower
Age
Co-Borrower
Age
AP 3
APPLICATION OF BORROWER
You are applying for the credit insurance marked above. Your signature below means that you agree that:
1. You are not eligible for insurance if you have reached your 65th birthday.
2. You are eligible for disability insurance only if you are working for wages or profit 30 hours a week or more on the Effective Date.
3. Only the Primary Borrower is eligible for life or disability insurance.
DISABILITY INSURANCE MAY NOT COVER CONDITIONS FOR WHICH YOU HAVE SEEN A DOCTOR OR A CHIROPRACTOR IN THE LAST SIX MONTHS.
(Refer to Total Disabilities Not Covered” in your certificate for Details)
Date
Primary Borrower
Age
AP 4
APPLICATION OF BORROWER
You are applying for the credit insurance marked above. Your signature below means that:
1. You are not eligible for insurance if you have reached your 65th birthday.
2. Your co-borrower is not eligible for life or disability insurance.
Date
Primary Borrower
Age
AP 5
APPLICATION FOR CREDIT INSURANCE
You are applying for the insurance marked above. Your signature below means that you agree that:
1. You are not eligible for insurance if you have reached your 65th birthday.
2. You do not have to buy any life insurance to be eligible for disability coverage, or vice versa.
3. You are eligible for disability coverage only if you are working for wages or profit, for 30 hours a week or more, on the Effective Date.
4. Only the Primary Borrower is eligible for disability insurance.
DISABILITY INSURANCE MAY NOT COVER CONDITIONS FOR WHICH YOU HAVE SEEN A DOCTOR OR A CHIROPRACTOR IN THE LAST SIX MONTHS.
(Refer to “Total Disabilities Not Covered” in your certificate for details.)
Date
Primary Borrower
Age
Co-Borrower
Age
THIS INSURANCE MAY BE ISSUED ONLY TO COVER BORROWERS WHO HAVE A LOAN UNDER THE INDUSTRIAL LOAN LAW OR THE CALIFORNIA FINANCE LENDERS LAW.
AP 6
APPLICATION OF BORROWER
You are applying for the credit insurance marked above. Your signature below means that you agree that you are not eligible for insurance if you have reached your 65th birthday.
Date
Primary Borrower
Age
Co-Borrower
Age
THIS INSURANCE MAY BE ISSUED ONLY TO COVER BORROWERS WHO HAVE A LOAN UNDER THE INDUSTRIAL LOAN LAW OR THE CALIFORNIA FINANCE LENDERS LAW.
AP 7
APPLICATION FOR CREDIT INSURANCE
You are applying for the insurance marked above. Your signature below means that you agree that:
1. You are not eligible for insurance if you have reached your 65th birthday.
2. You do not have to buy any life insurance to be eligible for disability coverage, or vice versa.
3. You are eligible for disability coverage only if you are working for wages or profit, for 30 hours a week or more, on the Effective Date.
4. Only the Primary Borrower is eligible for life or disability insurance.
DISABILITY INSURANCE MAY NOT COVER CONDITIONS FOR WHICH YOU HAVE SEEN A DOCTOR OR A CHIROPRACTOR IN THE LAST SIX MONTHS.
(Refer to “Total Disabilities Not Covered” in your certificate for details.)
Date
Primary Borrower
Age
THIS INSURANCE MAY BE ISSUED ONLY TO COVER BORROWERS WHO HAVE A LOAN UNDER THE INDUSTRIAL LOAN LAW OR THE CALIFORNIA FINANCE LENDERS LAW.
AP 8
APPLICATION FOR CREDIT INSURANCE
You are applying for the insurance marked above. Your signature below means that you agree that you are not eligible for insurance if you have reached your 65th birthday.
Date
Primary Borrower
Age
THIS INSURANCE MAY BE ISSUED ONLY TO COVER BORROWERS WHO HAVE A LOAN UNDER THE INDUSTRIAL LOAN LAW OR THE CALIFORNIA FINANCE LENDERS LAW.
AP 10
APPLICATION OF BORROWER
You are applying for the credit insurance marked above and authorizing the Creditor to add the charges for insurance to your loan each month as they become due. You ha e the right to stop this authorization Your signature below means that you agree that:
1. You are eligible for insurance as to each advance only if you are working for wages or profit 30 hours a week or more on the date you sign for the advance. If you are not, that particular advance will not be insured until you return to work.
You are insured only for advances actually received by you. You are not insured for any unused credit which may be available to you.
2. Each month the insurance charge is calculated by multiplying the insured outstanding principal balance of your loan on the billing date by the rate shown in the Schedule.
We can change the rate later on. But if we do, we will let you know in advance. The new rate will apply only to charges for insurance made after the date of the rate change.
3. Only the Primary Borrower is eligible for disability insurance.
4. Neither you nor your co-borrower are eligible for insurance after you have reached your 65th birthday, and insurance will also stop when you reach that age.
DISABILITY INSURANCE MAY NOT COVER CONDITIONS FOR WHICH YOU HAVE SEEN A DOCTOR OR A CHIROPRACTOR IN THE LAST SIX MONTHS. (Refer to “Total Disabilities Not Covered” in your certificate for details.)
Date
Primary Borrower
Date of Birth
Co-Borrower
Date of Birth
AP 11
APPLICATION OF BORROWER
You are applying for the credit insurance marked above and authorizing the Creditor to add the charges for insurance to your loan each month as they become due. You have the right to stop this authorization. Your signature below means that you agree that:
1. You are insured only for advances actually received by you. You are not insured for any unused credit which may be available to you.
2. Each month the insurance charge is calculated by multiplying the insured outstanding principal balance of your loan on the billing date by the rate shown in the Schedule.
We can change the rate later on. But if we do, we will let you know in advance. The new rate will apply only to charges made for insurance after the date of the rate change.
3. Neither you nor your co-borrower are eligible for insurance after you have reached your 65th birthday, and the insurance will also stop on the last day of the month during which you reach that age.
Date
Primary Borrower
Date of Birth
Co-Borrower
Date of Birth
AP 12
APPLICATION OF BORROWER
You are applying for the credit insurance marked above and authorizing the Creditor to add the charges for insurance to your loan each month as they become due. You have the right to stop this authorization. Your signature below means that you agree that:
1. You are insured for advances actually received by you. You are not insured for any unused credit which may be available to you.
2. Each month the insurance charge is calculated by multiplying the insured outstanding principal balance of your loan on the billing date by the rate shown in the Schedule.
We can change the rate later on. But if we do, we will let you know in advance. The new rate will apply only to charges made for insurance after the date of the rate change.
3. You are not eligible for insurance after you have reached your 65th birthday, and the insurance will also stop on the last day of the month during which you reach that age.
Date
Primary Borrower
Date of Birth
AP 13
APPLICATION OF BORROWER
You are applying for the credit insurance marked above. Your signature below means that you agree that the maximum amount of life insurance is $__________ for ages $__________for ages and $__________for ages__________
Date
Primary Borrower
Age
Co-Borrower
Age
AP 14
APPLICATION OF BORROWER
You are applying for the credit insurance marked above. Your signature below means that you agree that:
1. The maximum amount of life insurance is $__________for ages__________ $__________ for ages__________and $__________for ages__________.
2. The maximum monthly total disability benefit is $__________for ages,
$__________for ages__________and
$__________for ages.
3. Only the Primary Borrower is eligible for disability insurance.
4. You are eligible for disability insurance only if you are working for wages or profit 30 hours a week or more.
DISABILITY INSURANCE MAY NOT COVER CONDITIONS FOR WHICH YOU HAVE SEEN A DOCTOR OR A CHIROPRACTOR IN THE LAST SIX MONTHS.
(Refer to “Total Disabilities Not Covered” in your certificate for details.)
Date
Primary Borrower
Age
AP 15
APPLICATION OF BORROWER
You are applying for the credit insurance marked above. Your signature below means that you agree that the maximum amount of life insurance is $__________ for ages__________,$__________ for ages__________and $__________for ages__________
Date
Primary Borrower
Age
AP 16
APPLICATION OF BORROWER
You are applying for the credit insurance marked above. Your signature below means that you agree that:
1. The maximum monthly total disability benefit is $__________ for ages__________, $__________ for ages__________ and $__________ for ages__________.
2. Only the Primary Borrower is eligible for disability insurance.
3. You are eligible for disability insurance only if you are working for wages or profit 30 hours a week or more.
DISABILITY INSURANCE MAY NOT COVER CONDITIONS FOR WHICH YOU HAVE SEEN A DOCTOR OR A CHIROPRACTOR IN THE LAST SIX MONTHS.
(Refer to “Total Disabilities Not Covered” in your certificate for details.)
Date
Primary Borrower
Age
AP 17
APPLICATION OF BORROWER
You are applying for the credit insurance marked above. Your signature below means that you agree that:
1. The maximum amount of life insurance is $__________for ages__________, $__________ for ages__________ and $__________ for ages__________.
2. The maximum monthly total disability benefit is $__________for ages__________$__________for ages__________, and $__________ for ages__________.
3. Only the Primary Borrower is eligible for disability insurance.
4. You are eligible for disability insurance only if you are working for wages or profit 30 hours a week or more.
DISABILITY INSURANCE MAY NOT COVER CONDITIONS FOR WHICH YOU HAVE SEEN A DOCTOR OR A CHIROPRACTOR IN THE LAST SIX MONTHS.
(Refer to “Total Disabilities Not Covered” in your certificate for details.)
Date
Primary Borrower
Age
Co-Borrower
Age
AP 18
APPLICATION OF BORROWER
You are applying for the credit insurance marked above and authorizing the Creditor to add the charges for insurance to your loan each month as they become due. You have the right to stop this authorization. Your signature below means that you agree that:
1. You are eligible for insurance as to each advance only if you are working for wages or profit 30 hours a week or more on the date you sign for the advance. If you are not, that particular advance will not be insured until you return to work.
You are insured only for advances actually received by you. You are not insured for any unused credit which may be available to you.
2. Each month the insurance charge is calculated by multiplying the insured outstanding principal balance of your loan on the billing date by the rate shown in the Schedule.
We can change the rate later on. But if we do, we will let you know in advance. The new rate will apply only to charges for insurance made after the date of the rate change.
3. Only the Primary Borrower is eligible for life or disability insurance.
4. You are not eligible for insurance after you have reached your 65th birthday and insurance will also stop when you reach that age.
DISABILITY INSURANCE MAY NOT COVER CONDITIONS FOR WHICH YOU HAVE SEEN A DOCTOR OR A CHIROPRACTOR IN THE LAST SIX MONTHS.
(Refer to “Total Disabilities Not Covered” in your certificate for details.)
Date
Primary Borrower
Date of Birth
AP 19
APPLICATION OF BORROWER
You are applying for the credit insurance marked above and authorizing the Creditor to add the charges for insurance to your loan each month as they become due. You have the right to stop this authorization. Your signature below means that you agree that:
1. You are eligible for insurance as to each advance only if you are working for wages or profit 30 hours a week or more on the date you sign for the advance. If you are not, that particular advance will not be insured until you return to work.
You are insured only for advances actually received by you. You are not insured for any unused credit which may be available to you.
2. Each month the insurance charge is calculated by multiplying the insured outstanding principal balance of your loan on the billing date by the rate shown in the Schedule.
We can change the rate later on. But if we do, we will let you know in advance. The new rate will apply only to charges for insurance made after the date of the rate change.
3. Only the Primary Borrower is eligible for disability insurance.
4. You are not eligible for insurance after you have reached your 65th birthday and insurance will also stop when you reach that age.
DISABILITY INSURANCE MAY NOT COVER CONDITIONS FOR WHICH YOU HAVE SEEN A DOCTOR OR A CHIROPRACTOR IN THE LAST SIX MONTHS.
(Refer to “Total Disabilities Not Covered” in your certificate for details.)
Date
Primary Borrower
Date of Birth
AP 20
MEDICAL APPLICATION OF BORROWER
You are applying for the credit insurance marked above. You should understand that untruthful answers to these questions may cancel your insurance protection.
1. Date of Birth_______________ Place of Birth_______________ Height_____ft._____ in. Weight_____lbs. Sex_____M_____F.
2. Occupation______________________________ Employed By:
3. Are you now working 30 hours a week or more at your occupation? Yes___No___
4. Are you now in good health and free from the effects of any illness or injury? Yes___No___
1. 5. Have you, during the last five years, had, or been advised to have, advice or treatment for any of the following:
  a) Cancer, Tumor, Ulcer, Goiter, Thyroid, Asthma, Tuberculosis, Leukemia Yes___No___
  b) Mental or Nervous Disorder, Paralysis or Convulsions Yes___No___
  c) High Blood Pressure, Rheumatic Fever, Heart Disease, Stroke Yes___No___
  d) Diabetes, Sugar/Albumin in Urine, Prostate Disorder Yes___No___
  e) Impairment of Sight, Speech or Hearing Yes___No___
  f) Disease of Liver, Gall Bladder, Kidneys, or Lungs Yes___No___
  g) Disease or impairment of Bones, Joints, Glands or Muscles Yes___No___
  h) Strained Back, Slipped Disc or Sciatica Yes___No___
  i) Drug Addiction or Alcoholism Yes___No___
6. Are you now taking any kind of prescription medication? Yes___No___
7. Have you been told by a medical professional that you have AIDS or ARC? Yes___No___
8. Have you ever applied for Life, Accident and Health or Hospital Insurance that was declined or modified? Yes___No___
1. 1. You have read the questions and answers above and they are correct and complete, to the best of your knowledge and belief
2. 2. You are not eligible for insurance if you have reached your 65th birthday.
3. 3. You are eligible for disability insurance only if you are working for wages or profit 30 hours a week or more on the Effective Date.
4. 4. Only the Primary Borrower is eligible for disability insurance.
5. 5. AUTHORIZATION TO OBTAIN INFORMATION: You authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company, the Medical Information Bureau, consumer reporting agency, or employer having information available as to diagnosis, treatment and prognosis with respect to any physical or mental condition and/or treatment of you and any other non-medical information of you, to give to the ____________________ Insurance Company or its reinsurer any such information. You understand the information obtained by use of the Authorization will be used by the ____________________ Insurance Company or its reinsurer to determine eligibility for insurance and eligibility for benefits under the policy. Any information obtained will not be released by the ____________________ Insurance Company to any person or organization except to reinsuring companies, the Medical Information Bureau, or other persons or organizations performing business or legal services in connection with your application, claim, or as may be otherwise lawfully required or as you may further authorize.
  You may request a copy of this Authorization.
  This Authorization shall be valid for two and one half years from the date shown below. A photocopy of this Authorization is as valid as the original.
  DISABILITY INSURANCE MAY NOT COVER CONDITIONS FOR WHICH YOU HAVE SEEN A DOCTOR OR A CHIROPRACTOR IN THE LAST SIX MONTHS.
  (Refer to your Notice of Proposed Insurance for details.)”
  Date
  Primary Borrower or Co-Borrower
  MEDICAL INFORMATION BUREAU PRE-NOTICE
  (To be retained by Applicant or Proposed Insured)
  Information which you provide will be treated as confidential except that ____________________ Insurance Company or its reinsurer may, however, make a brief report to the Medical Information Bureau, a non-profit membership organization of life insurance companies which operates an information exchange in behalf of its members. On request by another member insurance company to which you have applied for life or health insurance coverage, or to which a claim is submitted, the M.I.B. will supply such company with the information it may have in its files. Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. (Disclosure of mental health information may be limited.) If you question the accuracy of information in the Bureau's file, you may contact the Bureau and seek a correction in accordance with the procedures set forth in the Fair Credit Reporting Act.
  The address of the Bureau's information office is Post Office Box 105, Essex Station, Boston, Massachusetts 02112, telephone number (617) 426-3660. ____________________Insurance Company may also release information in its file to other life insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted.
  AP 21
  APPLICATION OF BORROWER
  You are applying for the credit insurance marked above and authorizing the Creditor to add the charges for insurance to your loan each month as they become due. You have the right to stop this authorization. Your signature below means that you agree that:
6. 1. You are not eligible for insurance if you have reached your 65th birthday.
7. 2. You are eligible for disability insurance only if you are working for wages or profit 30 hours a week or more on the Effective Date.
8. 3. Each month the life insurance charge is calculated by multiplying the scheduled unpaid balance of your loan on the billing date by the rate shown in the Schedule. The monthly disability insurance charge is calculated by multiplying the total of the remaining scheduled monthly payments on your loan by the rate in the Schedule.
  We can change the premium rates later on. But if we do, we will let you know in advance. The new rates will apply only to charges for insurance made after the date of the rate change.
9. 4. Only the Primary Borrower is eligible for disability insurance.
  DISABILITY INSURANCE MAY NOT COVER CONDITIONS FOR WHICH YOU HAVE SEEN A DOCTOR OR A CHIROPRACTOR IN THE LAST SIX MONTHS.
  (Refer to “Total Disabilities Not Covered” in your certificate for details.)
  Date
  Primary Borrower
  Age
  Co-Borrower
  Age
  AP 22
  APPLICATION OF BORROWER
  You are applying for the credit insurance marked above and authorizing the Creditor to add the charges for insurance to your loan each month as they become due. You have the right to stop this authorization. Your signature below means that you agree that:
10. 1. You are not eligible for insurance if you have reached your 65th birthday.
11. 2. Each month the life insurance charge is calculated by multiplying the scheduled unpaid balance of your loan on the billing date by the rate shown in the Schedule.
  We can change the premium rates later on. But if we do, we will let you know in advance. The new rates will apply only to charges for insurance made after the date of the rate change.
  Date
  Primary Borrower
  Age
  Co-Borrower
  Age
  AP 23
  APPLICATION OF BORROWER
  You are applying for the credit insurance marked above and authorizing the Creditor to add the charges for insurance to your loan each month as they become due. You have the right to stop this authorization. Your signature below means that you agree that:
12. 1. You are not eligible for insurance if you have reached your 65th birthday.
13. 2. You are eligible for disability insurance only if you are working for wages or profit 30 hours a week or more on the Effective Date.
14. 3. Each month the life insurance charge is calculated by multiplying the scheduled unpaid balance of your loan on the billing date by the rate shown in the Schedule. The monthly disability insurance charge is calculated by multiplying the total of the remaining scheduled monthly payments on your loan by the rate in the Schedule.
  We can change the premium rates later on. But if we do, we will let you know in advance. The new rates will apply only to charges for insurance made after the date of the rate change.
15. 4. Only the Primary Borrower is eligible for disability insurance.
  DISABILITY INSURANCE MAY NOT COVER CONDITIONS FOR WHICH YOU HAVE SEEN A DOCTOR OR A CHIROPRACTOR IN THE LAST SIX MONTHS.
  (Refer to “Total Disabilities Not Covered” in your certificate for details.)
  Date
  Primary Borrower
  Date of Birth
  AP 24
  APPLICATION OF BORROWER
  You are applying for the credit insurance marked above and authorizing the Creditor to add the charges for insurance to your loan each month as they become due. You have the right to stop this authorization. Your signature below means that you agree that:
16. 1. You are not eligible for insurance if you have reached your 65th birthday.
17. 2. Each month the life insurance charge is calculated by multiplying the scheduled unpaid balance of your loan on the billing date by the rate shown in the Schedule.
  We can change the premium rates later on. But if we do, we will let you know in advance. The new rates will apply only to charges for insurance made after the date of the rate change.
  Date
  Primary Borrower
  Age
  AP 25
  APPLICATION OF BORROWER
  You are applying for the credit insurance marked above and authorizing the Creditor to add the charges for insurance to your loan each month as they become due. You have the right to stop this authorization. Your signature below means that you agree that:
18. 1. You are not eligible for insurance if you have reached your 65th birthday.
19. 2. You are eligible for disability insurance only if you are working for wages or profit 30 hours a week or more on the Effective Date.
20. 3. Each month the disability insurance charge is calculated by multiplying the scheduled monthly payments on your loan by the rate in the Schedule.
  We can change the premium rates later on. But if we do, we will let you know in advance. The new rates will apply only to charges for insurance made after the date of the rate change.
  DISABILITY INSURANCE MAY NOT COVER CONDITIONS FOR WHICH YOU HAVE SEEN A DOCTOR OR A CHIROPRACTOR IN THE LAST SIX MONTHS.
  (Refer to “Total Disabilities Not Covered” in your certificate for details.)
  Date
  Primary Borrower
  Date of Birth
Give details of any “No” answers to questions 3 and 4 and any “Yes” answers to questions 5, 6, 7 and 8. Include date, disease, injury or condition, and name and address of doctor or insurance company.
Your signature below means that you agree that:

AP 1

APPLICATION OF BORROWER

You are applying for the credit insurance marked above. Your signature below means that you agree that:

Note: Authority cited: Section 779.21 and 779.27, Insurance Code. Reference: Sections 779.6, 779.7, 779.27, 791.06, 799.06 and 10127.5, Insurance Code; Sections 18290-18292, 22314, 22315 and 22455, Financial Code; and Section 120980(f), Health and Safety Code.

History

1. Amendment filed 7-25-83; effective thirtieth day thereafter (Register 83, No. 31).

2. Amendment filed 5-23-85; effective thirtieth day thereafter (Register 85, No. 21).

3. Amendment of section and Note filed 10-2-2006; operative 11-1-2006 (Register 2006, No. 40).