Cal. Code Regs. tit. 10 § 2249.14
Insurer's Name and Complete Address
Called We or Us
SCHEDULE
Primary Borrower, called you, and Address
Co-Borrower, also called you
Source Code
Creditor Beneficiary and Insurance License Number
Class of Business
Secondary Beneficiary
Term of Insurance
Effective Date
Original Amount of Life Insurance
Scheduled Expiration Date
Monthly Loan Payment
Monthly Total Disability Benefit
| Decreasing Life: Single () joint () | Premium: |
| Disability: 30-day Elimination Period | Premium: |
Total Premium:
Maximum Monthly Disability Benefit:
Maximum Amount of Life Insurance:
Group Policy Number
Certificate Number
APPLICATION OF BORROWER
You are applying for the credit insurance marked above, Your signature below means that you agree that:
DISABILITY INSURANCE MAY NOT COVER CONDITIONS FOR WHICH YOU HAVE SEEN A DOCTOR OR A CHIROPRACTOR IN THE LAST SIX MONTHS. (Refer to "Total Disabilities Not Covered" in your certificate for details.)
| ___________________________ | ||||
| Date | Primary Borrower | Age | ||
| ___________________________ | ||||
| Co-Borrower | Age | |||
CERTIFICATE OF INSURANCE
You can cancel this insurance at any time by telling the creditor that you want to do so. You will get back ALL the premium you paid for this insurance if you tell us or the creditor to cancel it within 30 days after you receive this certificate. If you cancel this insurance after 30 days, you will not get back all the premium that you paid.
If you have a question, problem or complaint about this insurance, please contact the Creditor Beneficiary at the address and phone number shown in the Schedule or us at (insert address and telephone number of insurer). If we do not resolve your question, problem or complaint to your satisfaction, you may then contact the
California Department of Insurance
300 South Spring Street
Los Angeles, CA 90013
(800) 927-4357 or (213) 897-8921
WHAT YOU GET
We certify that if we have been paid the premium shown in the Schedule you are insured for the coverage shown in the Schedule, subject to the terms of the Group Policy issued to the Creditor.
WHO GETS PAID
Claim payments are made to the irrevocable Creditor Beneficiary named in the Schedule to pay off or reduce your debt. If claim payments are more than the balance of your debt, the difference will be paid to you or to the Secondary Beneficiary named in the Schedule, if any, or to your estate.
WHAT WE WILL PAY
Single Life Insurance Benefit. If you die while you are insured for single life coverage we will pay the amount of insurance in force at the time of your death after we receive proof of your death.
Joint Life Insurance Benefit. If you or your co-borrower die while insured for joint life coverage we will pay the amount of insurance in force at the time you or your co-borrower dies after we receive proof of the death. Only one death benefit is payable under this policy.
Amount of Life Insurance. The amount of life insurance is the scheduled unpaid balance due on the loan on the date of the insured borrower's death. The amount of life insurance does not include any delinquent payments or unearned interest.
Total Disability Insurance Benefit. If you are insured for total disability insurance, we will pay a benefit if you file written proof that you became totally disabled while insured and continue to be totally disabled for more than 30 days. Payment will be calculated from the 31st day of disability. The benefit will be equal to 1/30th of your Monthly Total Disability Benefit in the Schedule for each day of disability to be compensated. Payments will stop when you are not totally disabled any more or when benefits are paid to the Scheduled Expiration Date, whichever comes first.
Definition of Total Disability. During the first 18 consecutive months of total disability, total disability means that you are not able to perform the major duties of your occupation because of sickness or accidental injury. After the first 18 consecutive months of total disability, the definition changes and requires that you not be able to perform the duties of any occupation for which you are reasonably qualified by education, training or experience. You will be required to give us written proof of your continuing total disability from time to time.
WHAT WE WON'T PAY
Misstated Age. If you stated you are under 65, but you are not, we will return your premium when we discover this and will not pay any benefits. This also applies to your co-borrower, if you applied for joint life coverage.
Suicide. We won't pay any claim if you commit suicide within 6 months of the Effective Date shown in the Schedule, but we will refund the life insurance premium. This also applies to your co-borrower, if you applied for joint life coverage.
Total Disabilities Not Covered. We won't pay the claim or refund the disability premium if your disability:
WHEN INSURANCE STOPS--REFUNDS
You can stop this insurance at any time. This insurance stops on the Scheduled Expiration Date, or when your loan is paid off, renewed, refinanced or otherwise stops, whichever happens first. If your insurance stops before the Scheduled Expiration Date in the Schedule, you will be given a refund or a credit on your account of unearned premium. This refund or credit will be calculated using a formula approved by the Insurance Commissioner, but refunds or credits of less than $5.00 won't be made.
WHAT THE CONTRACT IS AND HOW YOUR STATEMENTS AFFECT IT
The Group Policy, the Application for the Group Policy, and the attached Application of Borrower are the complete contract of insurance. All statements made by you in your Application are considered to have been made to the best of your knowledge and belief. No statement can be used to void this insurance or deny a claim unless that statement is in your signed Application. After 2 years during your lifetime from the Date in the Application, no statement made by you in your Application can be used to void this insurance or deny a claim. This does not apply to your disability coverage (if any) if that statement was made fraudulently. If you stated in your Application that you are age 65 or older and we do not return your premium within 75 days of the Effective Date, you are insured.
RULES FOR FILING A TOTAL DISABILITY CLAIM
You must write us or our agent about your total disability claim within 30 days after the beginning of your total disability or as soon after that as you can. We will send you claims forms within 15 days after you tell us about the claim. If we don't send the forms in 15 days, you can simply send us written proof of your disability. The proof must show the date and the cause of the total disability and how serious it is, and it must be signed by a physician or a chiropractor. The proof of total disability must be sent to us no later than 90 days after the end of each period for which a total disability benefit is payable. If it is impossible to file within 90 days, you must file as soon as you can. Unless you have been legally incapable of filing the proof of total disability, we won't accept it if it is filed after one year from the time if should have been filed. You can't start any legal action until 60 days after you send us the proof of your total disability, and you can't start any legal action more than 3 years after the proof is filed.
RULES FOR FILING A LIFE CLAIM
We must be given a certified copy of the death certificate as proof of a life claim.
PHYSICAL EXAMINATION AND AUTOPSY
We at our own expense have the right, and you must allow us the opportunity, to examine your person as often as is reasonably required while a claim is pending and to make an autopsy in case of death, if it is not forbidden by law.
Cal. Code Regs. Tit. 10, § 2249.14
2. Amendment filed 7-25-83; effective thirtieth day thereafter (Register 83, No. 31).
3. Amendment filed 5-23-85; effective thirtieth day thereafter (Register 85, No. 21).
4. Amendment of section heading, section and NOTE filed 10-2-2006; operative 11-1-2006 (Register 2006, No. 40).
Note: Authority cited: Sections 779.21 and 779.27, Insurance Code. Reference: Sections 510, 779.2, 779.3, 779.4, 779.6, 779.14, 779.27, 779.30, 779.31, 1758.99, 10113, 10113.5, 10203.5, 10203.55, 10207, 10208, 10209, 10127.5, 10320, 10350-10350.3, 10350.5-10350.7, 10350.10, 10350.11, 10369.1 and 10369. 10, Insurance Code; and Section 120980(f), Health and Safety Code.
2. Amendment filed 7-25-83; effective thirtieth day thereafter (Register 83, No. 31).
3. Amendment filed 5-23-85; effective thirtieth day thereafter (Register 85, No. 21).
4. Amendment of section heading, section and Note filed 10-2-2006; operative 11-1-2006 (Register 2006, No. 40).