Application to Guarantee Trust Life Insurance Company

for Individual Graded Benefit Whole Life Insurance

1275 Milwaukee Avenue, Glenview, IL 60025, (800) 338-7452
PROPOSED INSURED SEND DOCUMENTS TO:  AGENT  INSURED
Last Name First Name M.I.
Home Address City State Zip
Phone Work ( ) Home ( )

Social Security Number  Male  Female Age Date of Birth(mm/dd/yy)

E-mail Address Weight lbs. Height ft. in.

Have you used any tobacco products in the last 12 months?  Yes  No

Plan Applied for: Graded Death Benefit Face Amount: $

Modal Premium Requested Effective Date

 Annual  Semi Annual Please Choose a Billing Option:
 Quarterly  Monthly
Select Billing Day
Billing Day: 1st - 28th

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OR  2nd Wednesday  3rd Wednesday  4th Wednesday

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Amount of Premium Collected:

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$

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Is Automatic Premium Loan Desired?  Yes  No

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Owner (Completed only if other than the proposed insured.)

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Full legal name of individual

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(First, Middle, Last), Institution or Trust

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Street Address City State Zip

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Home Phone Number ( ) Alternate Phone/Cell Number ( )

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Relationship to proposed insured Date of Birth (mm/dd/yy)

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 Male  Female

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Social Security/Tax ID Number

Beneficiary Information (Revocable)

Name of each primary beneficiary (Last, First, Middle Initial) Relationship to Insured % Share
total must
equal 100%
Name of each contingent beneficiary (Last, First, Middle Initial) Relationship to Insured % Share
total must
equal 100%
Do you have existing life insurance policies or annuity contracts?  Yes  No
Will the proposed insurance replace or change any existing life insurance policies or annuities?  Yes  No
If “Yes”, to the above questions, please provide the company name and submit necessary replacement forms.
________________________________________________________________________________________

APPL1-21-FL 1 16A652 (XH)

 If any answer to questions 1 through 6 is YES, you are not eligible for coverage.
1. Within the last twenty four (24) months, have you been receiving kidney dialysis, require daily
oxygen use (excluding CPAP), have an implanted defibrillator or received or been advised by a  Yes  No
licensed member of the medical profession to get an organ transplant?
2. Have you ever been diagnosed with or treated by a licensed member of the medical profession
for Alzheimer’s disease or dementia or are currently being treated for memory loss?  Yes  No
3. Within the last twenty four months, have you been diagnosed as having, or been prescribed
medication or been treated by a licensed member of the medical profession for cancer
(excluding Stage A Prostate Cancer, Carcinoma in Situ, Squamous Cell or Basal Cell  Yes  No
Carcinoma)?
4. Have you ever had or been recommended by a licensed member of the medical profession to
have an amputation due to complications from diabetes?  Yes  No
5. Are you currently bedridden, confined to a hospital, nursing home, mental care facility, long term
care facility, hospice or have you been diagnosed with an end-stage or terminal illness, or been  Yes  No
told by a licensed member of the medical profession that you have less than 12 months to live?
6. In the past 10 years have you been tested positive for exposure to the HIV infection or been
Diagnosed by a physician as having ARC or AIDS caused by the HIV infection or other sickness or  Yes  No
condition derived from such infection?
Secondary Addressee: You have the right to designate a secondary addressee to also receive notices of lapse or
termination of the policy for nonpayment of premium. If you wish to designate such a person, please complete below.

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Name:________________________________________________ Relationship:______________________

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Address:________________________________________________________________________________

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AUTHORIZATION TO RELEASE MEDICAL INFORMATION

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I authorize Guarantee Trust Life Insurance Company (herein referred to as the “Company”), insurance support

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organizations, authorized representatives, and any reinsurers, to obtain information as to the diagnosis, treatment, or

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prognosis of my physical condition, other coverage and criminal or motor vehicle records needed to underwrite my

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application for insurance. Upon presentation of this Authorization, or a photocopy of it, the Company may obtain, without

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restriction (except psychotherapy notes,) such information or records from any doctor, health professional, hospital, clinic, the

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Veterans Administration, insurance company, pharmacy benefit manager, pharmacies or pharmacy-related facility which have

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such information including any medical information provided to any affiliate insurance company on previous applications and

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medical information provided to our health division for underwriting or claim servicing purposes. The Company and its

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reinsurers may also obtain such information from MIB, Inc. I authorize the Company, or its reinsurers, to make a brief report of

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my personal health information to MIB, Inc. This Authorization includes all information about drugs, alcoholism, and mental

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illness. I understand and agree that the Company or its representatives may conduct a phone interview or face-to face
assessment as part of the underwriting process. Although federal regulations require that the Company inform me of the
potential that information disclosed pursuant to this authorization may be subject to re-disclosure and no longer be protected
if such information is disclosed to a person or entity not covered by the federal privacy regulation, all such information
received by the Company pursuant to this authorization will be protected by federal and state privacy laws and regulations. I
agree this authorization will be valid for 24 months from the date signed. The time limit complies with the time limit, if any,
permitted by applicable law in the state where the policy is delivered or issued for delivery. I or my authorized representative
may have a photocopy of it. I have read or had read this authorization and I have also received a copy or will be provided a
copy of the “Notice to Applicant, Parts 1 and 2” and the Description of Information Practices form prepared by Guarantee
Trust Life Insurance Company (if required by your state).
I understand that I have the right to revoke this Authorization, in writing, at any time by sending written notification to my
agent or to the Company at the above address. I understand that a revocation will not be effective to the extent the Company
has relied on the use or disclosure of the protected health information or so long as GTL has a legal right to contest a claim
under the coverage or the coverage itself. Revocation requests should be sent in writing to my agent or to the attention of the
Underwriting Manager. I understand once information is disclosed pursuant to this Authorization, such information will
continue to be protected by GTL in accordance with federal or state law. I also understand that my application for insurance
can be declined if I choose not to sign this Authorization.
This application may be completed by electronic or telephonic means. I acknowledge that the Company or its agent has
verified my identity for this purpose in accordance with any applicable law or regulation and that if completed by electronic
means, I have provided my consent and authorization to complete an electronic transaction to apply for coverage.
This authorization shall constitute an electronic signature, which is legally binding, and has the same effect as if I had physically
signed this application. If this application is completed by phone, I authorize the Company or its agent to accept my voice
signature response.

APPL1-21-FL 2 (XH)
I agree that I may receive my policy and other GTL correspondence in electronic format. I acknowledge receipt of the
Electronic Delivery and Communications Disclosure, which describes the requirements for Electronic Policy Fulfillment
and Communications, as well as my right to opt-out of Electronic Policy Fulfillment and receive a paper copy of my
policy free of charge.
I have read the questions and answers in all parts of this application and agree that they are complete and true to the
best of my knowledge and belief. I agree that this application shall form a part of any policy issued. No information
about the Proposed Insured will be considered to have been given to the Company unless it is stated in this application.
I understand and agree that no agent has the authority to waive a complete answer to any question in the application,
pass on insurability, make or alter any contract, or waive any of the Company’s other rights or requirements; that any
policy applied for shall not take effect unless and until the policy has been issued and delivered and the full first
premium, according to the mode of payment selected by the applicant (as permitted by the Company) and stipulated in
the policy, has been paid and accepted by the Company during the lifetime and condition of health of the Proposed
Insured as stated in the application.

Fraud warnings
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

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Signature of Proposed Insured Date

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Signature of Owner (if other than Proposed Insured) Date

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X_____________________________________________________________________________________________

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Title of Officer signing as owner if owner is a corporation, partnership, or trust

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X_____________________________________________________________________________________________

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Signature of Parent/Guardian or Person liable for any proposed insured’s support

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Signed at______________________________________________________________________________________

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City State/Zip Date

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Applicants Legal Address _________________________________________________________________________

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City State/Zip

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I certify that I have asked all questions and truly and accurately recorded the answers contained herein. To the best of my
knowledge and belief, the insurance applied for  is likely, or  is not likely to replace or change existing insurance or
annuities.

Signature of Soliciting Agent Signature of Secondary Agent

(Agent’s signature not required if not sold through agent)

Print Agent’s Name Florida licensed ID No. Print Agent’s Name Florida licensed ID No.

Agent’s E-mail Address Agent’s E-mail Address

Signed at
City State/Zip Date

APPL1-21-FL 3 (XH)
MONTHLY PRE-AUTHORIZED PREMIUM PAYMENT PLAN
Authorization to Honor Withdrawals to be drawn by Guarantee Trust Life Insurance Company.

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Name of my Bank My Bank’s Address City State Zip Code
As a convenience to me, I request and authorize you to charge the account shown below for premiums drawn by and
payable to the order of Guarantee Trust Life Insurance Company, Glenview, Illinois provided there are sufficient funds
in my account to pay the same upon presentation.

Account Number Bank Routing Number

Account Type:  Checking Account (Attach a Voided “Sample” check)

 Savings Account (Attach a Voided “Sample” check if applicable, or a Deposit slip)

I agree that my rights in respect to each payment shall be the same as if it were drawn by me and signed personally
by me. This authority is to remain in effect until revoked by me in writing and until you receive notice for which you
agree you will be fully protected in honoring such requests. I agree that if any such payment is not honored, whether

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with or without cause and whether intentionally, or inadvertently, you shall be under no liability at all although such

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action could result in the forfeiture of insurance.

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Printed name(s) of insured(s) if different from premium payer Premium payer’s signature, as it appears on bank records

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RECEIPT DATE

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Received of the sum of $ and application for insurance to Guarantee Trust Life

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Insurance Company. If for any reason the application is declined this payment will be refunded. No liability is created

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or assumed by the company, except for refund of this payment, until the insurance applied for has been issued.

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Agent’s Signature :

If you do not receive your policy/certificate within 60 days from the date of your application, please write to:
Guarantee Trust Life Insurance Company, 1275 Milwaukee Avenue Glenview, IL 60025
MAKE CHECK PAYABLE TO: GUARANTEE TRUST LIFE INSURANCE COMPANY
------------------------------------------------------------- Detach this Notice to Applicant and leave with applicant---------------------------------------------------------------

NOTICE TO APPLICANT – PARTS 1 AND 2

Part 1: Fair Credit Reporting Act and Privacy Act Pre-Notification
The application you completed for insurance with us, in most cases, gives us all the information we need. In
certain cases, we may need more information.

If we need more information, we may get it by talking to other persons you know including, but not limited to, your agent
or other insurance companies you have applied to. We may ask an independent “consumer reporting agency” to help
us verify facts or get additional facts.

We may collect information concerning your health, job and financial situation, as well as your character, general
reputation and mode of living. We will not collect information relating to your sexual orientation.

The personal information we obtain about you is treated as confi dential and will not be discussed to other persons
or organizations without your written authorization except to the extent necessary as permitted by law, for the conduct
of our business. But any information collected by a “consumer reporting agency” may be shared by the agency with
others who use such information, but only to the extent which the Fair Credit Reporting Act Permits. You have a right of
access, and right of correction, concerning recorded personal information obtained in our fi le. In order to exercise

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these rights, you must contact us in writing requesting access or correction.

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You have no access right to privileged information. If we used a “consumer reporting agency,” you have the right to: (1)

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ask to talk with them and (2) ask them about their report. You may write us for the name and address of the agency.

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This paragraph is not intended as a complete description of your right of access and correction. If you would like a

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more complete description of our insurance information and Privacy Protection Practices, please write: Guarantee

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Trust Life Insurance Company, 1275 Milwaukee Avenue Glenview, IL 60025.

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Part 2: Notification Regarding MIB, Inc.

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Information regarding your insurability will be treated as confidential. Guarantee Trust Life Insurance Company or

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its reinsurers may, however, make a brief report thereon to MIB, Inc., a non-profit membership organization of life

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insurance companies, which operates an information exchange on behalf of its members. If you apply to another

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member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, MIB,

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Inc., upon request, will supply such company with the information in its file. Upon receipt of a request from you, MIB,
Inc., will arrange disclosure of any information it may have in your file. If you question the accuracy of the information
in MIB, Inc.’s file, you may contact MIB, Inc., and seek a correction in accordance with the procedures set forth in the
federal Fair Credit reporting Act. The address to the MIB, Inc. information office is 50 Braintree Hill Park, Suite 400,
Braintree Massachusetts 02184-8734, telephone number (866) 692-6901, e-mail address infoline@mib.com.
Guarantee Trust Life Insurance Company or its reinsurers may also release information in its file to its reinsurer(s) and
to other life insurance companies to whom you may also apply for life or health insurance, or to whom a claim for
benefits may be submitted.

Guarantee Trust Life Insurance Company

1275 Milwaukee Avenue
Glenview, Illinois 60025
 GUARANTEE TRUST LIFE INSURANCE COMPANY

Consent for Use of Electronic Records and Electronic Signatures

PLEASE PRINT AND SAVE A COPY OF THIS DOCUMENT FOR YOUR RECORDS

In connection with your application for, or administration of, insurance underwritten by Guarantee
Trust Life Insurance Company (“GTL”), you are consenting to the use of Electronic Signatures
and Electronic Records. As part of your consent to the use of Electronic Signatures and Electronic
Records you acknowledge that you: (1) understand the terms and conditions of receiving insurance
documents, disclosures and other communications electronically; (2) have the necessary hardware
and software that allow you to receive and view Electronic Records; (3) have a valid active email
account*; and (4) are responsible for accessing, opening, and reading communication GTL sends
or makes available to you in electronic format. GTL will consider electronic communication to be
received by you upon successful delivery to the designated email address you provide. You also
acknowledge that your Electronic Signature is legally binding and enforceable and is the legal

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equivalent of your handwritten signature.

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*An active email address is not required for viewing and / or downloading a copy of your insurance

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coverage from GTL’s secure website.

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GTL is required by law to provide you with the following information relative to (i) electronic

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delivery of disclosures, notices and other electronic communications (collectively, “Electronic

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Records”) and (ii) Electronic Signature.

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Types of Electronic Records Covered by This Consent

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Unless you request otherwise, documents that form our insurance relationship will be provided to

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you electronically. Electronic Records include, but are not limited to:

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• Application(s) and related forms

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• Policy or certificate insurance fulfillment documents
• Disclosures and notices, where required by state and / or federal law
• Customer service forms and claim forms
• Responses to customer service or claim-related communications initiated by GTL or
you

Your consent does not apply to policy lapse or termination notices.

What You Need in Order to Receive or View Electronic Records

In order to access and view communications and documents GTL makes available to you
electronically, you must:
• Have access to the internet and be able to view, save and print Portable Document Files
(PDF) using software such as Adobe Acrobat Reader. Adobe Acrobat Reader can be
downloaded for free at http://get.adobe.com/reader/
• Maintain a valid active email address. It is your responsibility to provide GTL with
your complete and accurate email address, as well as provide prompt notification of
any change to it. To ensure Electronic Records are not blocked in email or spam filters,
please add GTL’s domain, gtlic.com, to your safe sender list.

GTL ETC/Rev. 817(PS)

Your Right to Request Paper Copies
To ensure you have them when you need them, it’s recommend that you print copies of the
Electronic Records GTL makes available to you, or save them to your personal computer or other
electronic device. However, you may request a paper copy of any Electronic Record listed above
free of charge. Except where prohibited by law, GTL may charge a nominal fee for additional
copies requested after the first. Your request can be sent in writing, by phone, or email as indicated
in the Company Contact Information, shown below.

Right to Send Paper

GTL reserves the right to provide paper copies in lieu of Electronic Records. This would be done
in the event of, but not limited to, a system outage, if fraud is suspected, or where the designated
email address you have provided does not accept emails from GTL.

Changes to the Terms and Conditions of Electronic Communication

GTL reserves the right to modify the terms and conditions stated herein. GTL will provide you
with notice electronically of such change, its effective date, and your choices under the new terms
and conditions.

Withdrawal of Consent

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You may elect to withdraw your consent for Electronic Records at any time by contacting us in

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writing, by phone, or through the Policyholder - Customer Service link on GTL’s website. Please

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see the Company Contact Information below.

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Company Contact Information
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1. Write us at…

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Guarantee Trust Life Insurance Company

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ATTN: Policyholder Service

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1275 Milwaukee Avenue

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Glenview, IL 60025

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2.
u Call us toll-free at…
1-800-338-7452

3. Contact us by email by visiting our website…

Go to www.gtlic.com. Click on the Customer Service tab at the top of the screen and
choose Customer Support. In the Customer Support site there is a Contact Us option you
may use to email us your request.

GTL ETC/Rev. 817(PS)