Topic summaries do not replace the original application questions. Your agent will confirm the application and payment arrangements for your product and state.
Read 5Star original brochure, rates and application package (PDF). Original page order and wording are unchanged.
Spouse enrollment, when elected
Original page 3
Application fields
- first name
- last name
- DOB
- gender
- coverage amount
- one primary beneficiary name/relationship at100%
Child rider, when elected
Original page 3
Application fields
- up to7 children: first name/last name/DOB/gender
- one primary beneficiary name/relationship at100%, shared by all children
Policy and agent information
Original page 3
Application fields
- effective date
- signature date
- group number
- group situs state
- agent numbers and split percentages, maximum4 agents
Employee information
Original page 4
Application fields
- date of hire
- last name
- first name
- DOB
- SSN
- gender
- phone (printed optional)
- address
- city/state/ZIP
Employee coverage, when elected
Original page 4
Application fields
- coverage amount
- occupation class
- up to4 primary beneficiaries: name/percentage/relationship, total100%
- one contingent beneficiary: name/relationship at100%
Statement of Insurability
Original page 5
Application fields
- employer/group name
- employee/owner name
- SSN
- separate employee/spouse yes/no answers
Question topics
- I: five-year AIDS/related complex/immune-system disorder diagnosis, treatment or medication
- II: six-month inability to work, personal/medical walking/bathing/dressing assistance or confinement/hospitalization; retain exclusions and hospitalization definition
- III: twelve-month recommended diagnostic testing, surgery or hospitalization incomplete, or results not received
- IV A: five-year listed heart, stroke, cancer, lung/chronic respiratory, insulin-diabetes, liver or kidney conditions; retain oxygen/asthma qualifications
- IV B: two or more DUI convictions
- IV C: alcohol/drug dependency treatment/counseling or advice to reduce/discontinue alcohol
- V: life insurance applied for and rejected within ten years
Conditions, authorization and signatures
Original page 6
Application fields
- personal employee/certificate-owner signature
- employee date/city/state
- separate spouse signature if spouse coverage elected
- spouse date/city/state
Back to application guide heading
No applicant answers, completed forms, signatures or payment instructions are collected here. Read the original application for exact wording.