Topic summaries do not replace the original application questions. Your agent will confirm the application and payment arrangements for your product and state.
Read AFR application — original SAMPLE (PDF). Original page order and wording are unchanged.
Group information
Original page 1
Application fields
- employer/group name
- group number
Employee/member
Original page 1
Application fields
- name
- SSN
- gender
- birth date
- address
- city
- state
- ZIP
- phone
- actively at work yes/no and definition
Employee/member coverage
Original page 1
Application fields
- coverage amount
- premium mode
- premium amount
- two primary beneficiaries: name/relationship/SSN/DOB
- two contingent beneficiaries: name/relationship/SSN/DOB
Dependent coverage
Original page 1
Application fields
- spouse name/SSN/gender/DOB
- spouse coverage/premium
- spouse primary and contingent beneficiary
- child rider coverage/premium
- three children: name/SSN/gender/DOB
Statement of insurability
Original page 2
Question topics
- I: five-year AIDS/AIDS-related-complex/immune-system-disorder diagnosis, treatment or medication
- II: spouse six-month inability to work, walking/bathing/dressing assistance or confinement/hospitalization; printed exclusions retained
- III A: five-year listed heart/stroke/cancer/lung/respiratory/insulin-diabetes/liver/kidney conditions
- III B: two or more DUI convictions
- III C: alcohol/drug dependency treatment, counseling or advice to reduce/discontinue
- IV: ten-year rejected life application
- V: twelve-month recommended testing/surgery/hospitalization incomplete or results not received
Conditions
Original page 3
Back to application guide heading
No applicant answers, completed forms, signatures or payment instructions are collected here. Read the original application for exact wording.