S.D. Admin. R. 20:06:06 app B
APPENDIX B
Insured Debtor | John Doe Box 555 Anywhere, USA, 55555 | Date of Birth | Age | Certificate Number | ||||||||||||||||||
Joint Insured Debtor | ||||||||||||||||||||||
Creditor (Beneficiary) (Name and Address) | ABC Bank 555 AVENUE Anywhere, USA 55555 | Creditors Insurance Account No | ||||||||||||||||||||
Assignee (Name and Address) | Monthly Payment | Annual Simple Interest Rate | ||||||||||||||||||||
Second Beneficiary | Relationship | |||||||||||||||||||||
EFFECTIVE DATE | EXPIRY DATE | Days to 1st Payment | ||||||||||||||||||||
COVERAGES | INITIAL AMOUNT OF INSURANCE | PREMIUMS | TERM IN MONTHS | |||||||||||||||||||
[] Gross or | [] NET | [] W. Dism | [] W/O Dism | |||||||||||||||||||
[] Decreasing Term | [] Periodic Decreasing Term | $ 5,400.00 | $ - | 36 | ||||||||||||||||||
[] Jt. Decreasing Term | [] Jt. Periodic Decreasing Term | |||||||||||||||||||||
[] Level Term | [] Jt. Level Term | $ 11,197.00 | $ - | 36 | ||||||||||||||||||
35 | Payments of $ | $150.00 | $ 5,400.00 | $ - | 36 | |||||||||||||||||
Final Payment of $ | $11,347.51 | [$150.00 Monthly Disability Benefit] | $ - | PREMIUM <-TOTAL | ||||||||||||||||||
[] Disability Coverage (Insured Debtor Only) | ||||||||||||||||||||||
WAITING PERIOD ELIMINATION PERIOD | ||||||||||||||||||||||
[] 7 Days | Retrospective | 0 Days | ||||||||||||||||||||
[] 14 Days | Retroactive | 0 Days | Maximum Monthly Disability (per debtor) | Maximum Monthly Disability (per debtor) | Maximum Term | Maximum Issue Age 65 Inclusive | ||||||||||||||||
[] 30 Days | Retroactive | 0 Days | ||||||||||||||||||||
[] 14 Days | Non-Retro | 14 Days | ||||||||||||||||||||
[] 30 Days | Non-Retro | 30 Days | ||||||||||||||||||||
$1000.00 (Ages 18-65) | $100,000.00 Ages 18-65) | 120 Months | ||||||||||||||||||||
DEATH CLAIM STATEMENT- INSTRUCTIONS: Creditor Policyholder should complete the statement below and return with the following documents: 1. Certified copy of the Death Certificate showing cause of death; 2. Copy of the conditional sales contract or note covered by the Insurance; 3. Copy of the Policy or Certificate Issued to the deceased. This completed form, together with the documents specified above, should be sent to: | ||||||||||||||||||||||
ABC ASSURANCE COMPANY Insurance Division, 555 Boulevard, Anywhere, USA, 55555-555 | ||||||||||||||||||||||
1. Name of Insured | ||||||||||||||||||||||
2. Certificate No. (or individual Policy No.) | Date of Loan | for Term of | Mos. | |||||||||||||||||||
3&&&&&&&&&&&&& | Original Amount Insured | &&&&&&&&&&&. | $ - | |||||||||||||||||||
4&&&&&&&&&&&&& | Less Amount Paid | &&&&&&&&&&&. | $ - | To comply with certain State Laws, our payoff to a creditor may be for the net amount due (Gross amount less unearned interest and/or advance payments). Please advise us of this amount. Any remaining balance is payable to the second beneficiary if named, otherwise to the Debtors Estate. | ||||||||||||||||||
5&&&&&&&&&&&&& | Less Unearned Interest | &&&&&&.&&&& | $ - | |||||||||||||||||||
6&&&&&&&&&&&&& | Less Unearned A & H Premium (Life Premium Earned) | &&&&&&&&&&& | $ - | |||||||||||||||||||
7&&&&&&&&&&&&& | Balance Due | &&&&&&&&&&& | $ - | |||||||||||||||||||
8&&&&&&&&&&&&&. | Number of Monthly Payments in Default at Death | |||||||||||||||||||||
9&&&&&&&&&&&&&. | Creditor Policyholder's Name | "Insurance Account No." | ||||||||||||||||||||
Street Address | City | State | Zip Code | |||||||||||||||||||
I hereby certify that the above answers are complete and true, and the balance due is the amount in line 7. | ||||||||||||||||||||||
Date: | By: | Title: | ||||||||||||||||||||
PREMIUM REFUND RECEIPT SCHEDULE | Send to: P.O. Box 555 Anywhere, USA 55555-555 | |||||||||||||||||||||
MO. | DAY | YEAR | LIFE | DISABILITY | TOTAL | |||||||||||||||||
DATE OF CANCELLATION | PERCENT UNEARNED | % | % | |||||||||||||||||||
POLICY CERTIFICATE WAS IN FORCE | MONTHS | AMOUNT OF REFUND | % | % | ||||||||||||||||||
I understand, hereby request cancellation of the above numbered certificate or policy as of 12:00 noon, Standard Time, as of the date of cancellation shown above. I hereby acknowledge receipt of the amount of refund shown above as a full refund of the unearned portion of the premium and hereby release ABC Company from all further liability under said certificate (s) or policy(ies)) as the case may be | ||||||||||||||||||||||
Date | ||||||||||||||||||||||
AGENT OR WITNESS | SIGNATURE OF INSURED | |||||||||||||||||||||
Name of Creditor | Address | |||||||||||||||||||||
S.D. Admin. R. 20:06:06 app B