DENISE FORCONI AZ WASHINGTON NATIONAL DIRECT MASTER

Do I REALLY need these benefits?

Watch this 1:30 video so you can make an educated decision for you & your family
Get Covered with George!
YOU CAN DOWNLOAD BROCHURES FOR EACH PLAN HERE:

ACCIDENT BROCHURE

LUMP SUM CRITICAL ILLNESS & CANCER BROCHURE

HOSPITAL INDEMNITY BROCHURE

* Products, riders and rates can vary slightly by state
ACCIDENT ASSURE with Physician's Office Additional Benefit

24/7 Cash in your pocket for accidents and injuries. No Health questions for this GREAT COVERAGE!
Choose a level of Accident Coverage - Monthly Rates*

You Only - $28.20You + Children - $39.50You + Spouse - $38.20You + Spouse + Children - $52.30NO THANKS, I am Waiving Accident
HOSPITAL ASSURE

$3000 in Hospital Indemnity with Outpatient, Emergency Room, Rehab Facility Benefits! 24/7 Coverage!

RATE CHART - MONTHLY

AGES	You	1 Parent Family	You/Spouse	2 Parent Family
18-49	$45.52	$57.94	$80.21	$95.40
50-59	$60.13	$73.18	$106.69	$121.92
60-64	$89.36	$107.23	$156.38	$178.72
65-69	$125.01	$150.01	$218.76	$250.01

Choose a level of Hospital Indemnity Coverage - Monthly Rates*

You OnlyYou + ChildrenYou + SpouseYou + Spouse + ChildrenNO THANKS, I am Waiving Hospital
ACTIVE CARE - LUMP SUM CRITICAL ILLNESS AND CANCER COVERAGE - Includes Radiation and Chemotherapy Upgrades.

Receive $10,000 in Critical Illness and Cancer Coverage.
1. Has any person proposed for coverage used any tobacco products or any type of nicotine substitute in the past 10 years?*

YesNo

LOOK AT THE RATE CHARTS BELOW.

1. DETERMINE YOUR BENEFIT AMOUNT YOU WANT (EITHER $10,000 OR $20,000)

2. LOOK AT YOUR AGE GROUP & YOUR LEVEL OF HOUSEHOLD COVERAGE. RATES WILL NOT INCREASE AS YOU GET OLDER.

3. DETERMINE YOUR COVERAGE AND LOCK IN YOUR RATE!

$10,000 in Lump Sum Benefit - Non Tobacco - Monthly Rate Chart

AGES	YOU	1 Parent Family	You & Spouse	2 Parent Family
18-39	$15.60	$18.10	$31.20	$33.70
40-44	$22.10	$24.60	$44.20	$46.70
45-49	$30.10	$32.60	$60.20	$62.70
50-54	$38.60	$41.10	$77.20	$79.70
55-59	$47.20	$49.70	$94.40	$96.90
60-64	$56.40	$58.90	$112.80	$115.30
65-69	$62.50	$65.00	$125.00	$127.50

2. Choose an option level for $10,000 in CI/Cancer Benefit.*

You OnlyYou + ChildrenYou + Spouse2 Parent FamilyNo Thanks, I am Waiving
APPLICATION FOR COVERAGE

Must be filled out completely
Primary Applicant's Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
State of Birth*
If Born outside of the US, please indicate country
Height blanks* Weightblank*
Your Age*
SSN#*
SSN# is required to enroll. If Waiving all coverage please type NONE
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Gender*

MaleFemale
Are you covering a Spouse?*

YesNo
Spouse's Name

First NameLast Name
Spouse's Age*
Spouse's DOB

MonthDayYear
Date
Spouse's State of Birth*
If Born outside of the US, please indicate country
Spouse Height blanks* Spouse's Weightblank*
Spouse's Gender

MaleFemale
Spouse's SSN#
How many dependent children are you covering?*
Child#1 Name

First NameLast Name
Child#1 DOB

MonthDayYear
Date
Child#1 Gender

MaleFemale
Child#1 Sate of Birth
Child#2 Name

First NameLast Name
Child#2 DOB

MonthDayYear
Date
Child#2 Gender

MaleFemale
Child#2 State of Birth
Child#3 Name

First NameLast Name
Child#3 DOB

MonthDayYear
Date
Child#3 Gender

MaleFemale
Child#3 State of Birth
Child#4 Name

First NameLast Name
Child#4 DOB

MonthDayYear
Date
Child#4 Gender

MaleFemale
Child#4 State of Birth
Child#5 Name

First NameLast Name
Child#5 DOB

MonthDayYear
Date
Child#5 Gender

MaleFemale
Child#5 State of Birth
Child#6 Name

First NameLast Name
Child#6 DOB

MonthDayYear
Date
Child#6 Gender

MaleFemale
Child#6 State of Birth
Beneficiary's Information

In case of accidental death
Beneficiary's Name (you can add more benefactors after policy has issued)*

First NameLast Name
Beneficiary's Relationship to you: *
Beneficiary's Percentage*
1. Will this insurance replace any accident and sickness insurance currently in force with us or another company for any person to be insured?*

YesNo
LUMP SUM CRITICAL ILLNESS/CANCER APPLICATION QUESTIONS: This plan includes radiation and chemotherapy upgrades.

All Questions Must be Answered Completely (Any "Yes" answer may disqualify an individual from coverage):
2. Do you own any other accident, hospital indemnity and/or disability insurance which is not being ended (not including Worker’s Compensation)?*

YesNo
1. Will this insurance replace any accident and sickness insurance currently in force with us or another company for any person to be insured?

YesNo
2. Has any person proposed for coverage used any tobacco products or any type of nicotine substitute in the past 10 years?*

YesNo
If “Yes” to question 3, the named individual(s) is not eligible for coverage. Please list individual(s) name:
3. In the past 10 years, has any person proposed for coverage been treated for or diagnosed by a health care provider as having Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?*

YesNo
4. Has any person proposed for coverage had within the past 5 years: Blood Disorder Cancer or any malignancy Carcinoma Chronic Obstructive Pulmonary Disease (COPD) Cirrhosis Emphysema Hepatitis B or C Hodgkin’s Disease Leukemia Lymphoma Malignant Tumor Sarcoma*

YesNo
5. Within the last 5 years, has any person proposed for coverage been treated for or diagnosed as having a pre-malignant condition or a condition with malignant potential?*

YesNo
6. In the past 12 months has any person proposed for coverage been advised by a health care provider to have surgery, to seek treatment, medical advice, or diagnostic tests that have not been completed or have diagnostic test results that are pending, for any conditions listed in question number 4 or in question number 5?*

YesNo
7. In the past 12 months has any person proposed for coverage had any abnormal diagnostic test results that were not more recently contradicted or negated by normal test results, if any, for any condition listed in question number 4 or in question number 5?*

YesNo
If “Yes” to question 4, 5, 6, or 7 the named individual(s) is not eligible for coverage. Please list individual(s) name:
8. Has any person proposed for coverage had within the past 5 years: Angina Cardiomyopathy Congestive heart failure(CHF) Coronary angioplasty(stent) Coronary artery disease(CAD) Coronary bypass surgery Heart Attack(MI) Heart Disease Heart Surgery Peripheral Vascular Disease Prescribed Nitroglycerin Stroke(CVA) Transient Ischemic Attack(TIA) Uncorrected Congenital Heart Defect Vascular Insufficiency Any other Cerebrovascular Disease Any other abnormality of the heart*

YesNo
9. Has any person proposed for coverage had a blood pressure reading in the last 6 months of greater than 150 systolic or 95 diastolic?*

YesNo
10. In the past 12 months has any person proposed for coverage been advised by a health care provider to have surgery, to seek treatment, medical advice, or diagnostic tests that have not been completed or have diagnostic test results that are pending, for any conditions listed in question number 8?*

YesNo
11. In the past 12 months has any person proposed for coverage had any abnormal diagnostic test results that were not more recently contradicted or negated by normal test results, if any, for any condition listed in question number 8?*

YesNo
If “Yes” to question 8, 9, 10, or 11 the named individual(s) is not eligible for coverage. Please list individual(s) name:
HOSPITAL ASSURE: APPLICATION QUESTIONS:

All Questions Must be Answered Completely (Any "Yes" answer may disqualify an individual from coverage):
1. In the past 5 years, has any person proposed for coverage been treated for or diagnosed by a health care provider as having Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS)?*

YesNo
2. In the past 5 years, has any person proposed for coverage been treated for or diagnosed by a health care provider as having any of the following conditions? Chronic Obstructive Pulmonary Disease (COPD) Chronic Bronchitis Emphysema Pulmonary Fibrosis Cystic Fibrosis Transient Ischemic Attack (TIA) Stroke / Cerebrovascular accident (CVA) Heart Attack (MI) Uncorrected Congenital Heart Defect Congestive heart failure (CHF) Coronary angioplasty with or without stent Coronary artery bypass surgery (CABG) Cardiomyopathy Sickle Cell Anemia Systemic Lupus Erythematosus (SLE) Multiple Sclerosis (MS) Muscular Dystrophy Psoriatic Arthritis Diabetes (DM) diagnosed prior to age 40 (not including gestational diabetes) Diabetes requiring insulin Diabetic complications requiring hospitalization Amputation(s) due to diabetic complications Organ or Bone Marrow Transplant Any Cancer or malignancy other than nonmelanoma skin cancer Liver disease or disorder Kidney Disease Epilepsy/Seizure disorder Drug or Alcohol Abuse*

YesNo
3. In the past 3 years, has any person proposed for coverage been treated for or diagnosed by a health care provider as having any of the following conditions? Angina Coronary Artery Disease Cardiac Pacemaker Implantable Cardiac Defibrillator (ICD) Atrial Fibrillation Alzheimer’s Disease or other condition known to cause irreversible cognitive impairment Dementia Parkinson’s Disease Peripheral Vascular Disease (PVD) Crohn’s Disease Ulcerative Colitis or proctitis Pancreatitis*

YesNo
4. Is any person proposed for coverage currently confined to a hospital or nursing home, or has a health care provider recommended such confinement?*

YesNo
5. Is any person proposed for coverage currently pregnant, an expectant parent, or undergoing infertility treatments?*

YesNo
6. In the past 12 months, has any person proposed for coverage had any medical condition(s) for which any medical or surgical procedure(s) (excluding cosmetic procedures) have been discussed, recommended, or planned with a health care provider, and are not yet completed?*

YesNo
7. In the past 12 months, has any person proposed for coverage been advised by a health care provider to have surgery, to seek treatment, medical advice, or diagnostic tests (excluding any tests performed for HIV or AIDS), that have not been completed or have diagnostic test results that are pending, for any conditions listed in question number 2 or in question number 3?*

YesNo
8. In the past 12 months, has any person proposed for coverage had any abnormal diagnostic test results that were not more recently contradicted or negated by normal test results, if any, for any condition listed in question number 2 or in question number 3?*

YesNo
If “Yes” to any questions 1 through 8 the named individual(s) is not eligible for coverage. Please list individual(s) name:
Request to draft premium by Electronic Funds Transfer (EFT)

Home office will process the draft for the initial premium within 48 hours of receiving the application.
By signing this form you are acknowleging:

I am aware that the draft may be processed within 48 hours of receipt of this request
in the home office.

You are authorizing subsequent renewal premiums to be deducted from the bank accountlisted below. These premiums will be deducted on a monthly basis on the first day of the month.
APPLICANT NAME

First NameLast Name
Date of birth or SSN
Accountholder Name (If Different)

First NameLast Name
Financial institution/Bank name
Bank Routing number
Bank Acount number
Type of Account:

CheckingSavings
Date

MonthDayYear
Date
Please Sign Here to Confirm Elections and withdrawal from banking institution.*

Clear
Should be Empty:

AGES	YOU	1 Parent Family	You & Spouse	2 Parent Family
18-39	$20.20	$22.10	$40.40	$42.30
40-44	$29.20	$31.10	$58.40	$60.30
45-49	$39.60	$41.50	$79.20	$81.10
50-54	$51.10	$53.00	$102.20	$104.10
55-59	$63.00	$64.90	$126.00	$127.90
60-64	$75.70	$77.60	$151.40	$153.30
65-69	$85.10	$87.00	$170.20	$172.10

Do I REALLY need these benefits?

ACCIDENT ASSURE with Physician's Office Additional Benefit

HOSPITAL ASSURE

ACTIVE CARE - LUMP SUM CRITICAL ILLNESS AND CANCER COVERAGE - Includes Radiation and Chemotherapy Upgrades.

APPLICATION FOR COVERAGE

Beneficiary's Information

LUMP SUM CRITICAL ILLNESS/CANCER APPLICATION QUESTIONS: This plan includes radiation and chemotherapy upgrades.

HOSPITAL ASSURE: APPLICATION QUESTIONS:

Request to draft premium by Electronic Funds Transfer (EFT)