Wellabe E-Application

Disclaimer*
If you use the CORE team, the CORE team member who takes the application will be listed as the Agent of Record. If you submit Directly with Great Western yourself, you will be listed as the Agent of Record.
Agent Information
Agent Name*
First Last
Agent Phone Number*
Agent Email:*
American Family Agent Number:*
Agent Date of Birth:*
MM slash DD slash YYYY
Business Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
License Information
National Producer Number:*
Applicant Information (Proposed Insured)
Applicant Name:*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Mobile Phone (if different from above)
Applicant Email:*
Owner (Complete only if other than proposed insured)
Will the Proposed Insured be the Owner?*
- No
- Yes
Owner Name
First Last
Date of Birth*
MM slash DD slash YYYY
Gender*
- Male
- Female
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email Address:*
Relationship to Insured:*
Policy Information
Please select one of the following:*
- Guaranteed Assurance
- Graded Benefit
- Great Assurance
Death Benefit Amount/Face Amount: (please pick one)*
Payment Frequency:*
- Monthly
- Quarterly
- Semi-Annually
- Annually
Optional benefit riders:
- Dependent Child/Grandchild Rider (will need to complete separate application)
- Accidental Death Rider (only available with Great Assurance Final Expense)
Total Premium Amount ($):*
Authorization
I, the proposed insured, authorize any physician, hospital, pharmacy, pharmacy benefit manager, health insurance plan or any other entity that possesses any diagnosis, treatment, prescription or other medical information about me to furnish such health information to Great Western Insurance Company and the entities with which it contracts to administer insurance application (collectively OCI) and their agents and representatives for the purpose of evaluating my eligibility for insurance. This medical or health information may include information on the diagnosis and treatment of mental illness, alcohol, and drug use. This also includes information on diagnosis, treatment, and testing results related to HIV, AIDS, and sexually transmitted diseases, unless otherwise restricted by state law. This authorization overrides any restrictions that I may have in place with any entity regarding the release of my medical information. Health information obtained will not be re-disclosed without my authorization unless permitted by law, in which case it may not be protected under federal privacy rules. This authorization shall be valid for two years from this date and may be revoked by sending written notice to the OCI. Non-health information is all other information. It may be about employment, other insurance owned, or motor vehicle, consumer or credit reports. It may also be information used to confirm questions and answers on the application for insurance. I authorize disclosure of this information to the OCI by any of the following sources: doctors, medical Practitioners, hospitals, clinics, or other medical or medically related facilities or professionals; the OCI's legal representatives or agents; insurers or reinsurers; health plans; consumer reporting agencies; public records; employers; Pharmacy Benefit Manager (PBM); or the Medical Information Bureau (MIB). I authorize OCI or its reinsurers to make a brief report of my personal health information to the MIB. I affirm that no illustration was used in the sale of this product. I understand: I can refuse to sign this Authorization. If I refuse, OCI will not be able to consider my application(s). I can revoke this Authorization at any time, except to the extent that OCI has acted in reliance upon it or other law that gives OCI the right to contest a claim under the policy or the policy itself. Revoking this Authorization mean that OCI will not be able to consider my application(s). Requests to revoke must be in writing and sent to: Great Western Insurance Company, P.O. Box 14410, Des Moines, Iowa 50306-3410. Subject to state and federal laws, information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient and may no longer be protected. I(or my authorized personal representative) am entitled to and will be sent a copy of this Authorization. This, Authorization expires in 24 months from the date I sign it. This 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 may request to be interviewed in connection with the preparation of a consumer report and, upon written request, receive a copy of the report. I agree that a copy of this Authorization is as valid as the original. FRAUD WARNING: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.
Agent Certification
I certify that I have presented this guaranteed issue whole life product to my client and they have agreed to purchase the product and are ready to submit an application to the carrier.
Agent Full Name*
First Last
Date*
MM slash DD slash YYYY
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If after clicking the submit button if you do not see your request has been submitted, a problem may have occurred so please contact lifesales@ociservices.com to make sure the e-app was received.

Wellabe E-Application

Agent Information

License Information

Applicant Information (Proposed Insured)

Owner (Complete only if other than proposed insured)

Policy Information

Authorization

Agent Certification