Online Application
CHARTERED BY THE CONGRESS OF THE UNITED STATES
FRATERNAL LIFE INSURANCE
FOUNDED IN 1896
March 2, 1907 A.D.
Phone: (202) 328-2630
Fax: (202) 328-7984

HUNGARIAN REFORMED FEDERATION OF AMERICA
A FRATERNAL BENEFIT SOCIETY
WASHINGTON, D.C.
(HEREINAFTER REFERRED TO AS "THE FEDERATION")

APPLICATION FOR ADULT INSURANCE

PART I.

QUESTIONS BELOW APPLY TO THE PROPOSED INSURANCE OF THE APPLICANT. ALL STATEMENTS IN THIS APPLICATION ARE REPRESENTATIONS, NOT WARRANTIES.

1. A.   Name of proposed insured.
First
Middle
Last
  (If married woman, maiden name also).
Maiden
  B.   Sex: Male    Female 
  C.   Marital Status: Single   Married   Widowed   Divorced   Separated
  D.   Social Security Number: - -
2. A.   Date of Birth: (MM/DD/YYYY) / /
  B.   Age: (Nearest Birthday)
  C.   Place of Birth:
City
State
  D.   Religion:
3. A.   Address:
Street
City
State
ZIP -
Phone
E-mail
4. A.   Plan of insurance applied for:
  B.   Amount: $  
  C.   State requested riders:
  D.   Amount: $  
5. A.   Method of payment: Monthly   Quarterly Semi-annually   Annually   SPWL
6. Beneficiary(ies).
Primary.
Full name
Relation
Secondary.
Full name
Relation
7. A.   Occupation and Duties:
  B.   Do you fly or intend to fly as a pilot or crew member?
(If yes, please fill out questionnaire)		 Yes    No 
8. Is the Applicant a member of the Federation? Yes    No  Certificate No.
  B.   List all life insurances in force on life of Applicant:
 
Company
Amount
Date issued
Company
Amount
Date issued
9. Is the insurance applied for intended to replace in whole or in part, any existing policy?
Yes    No 
Company
Amount: $
10. Have you ever made application for Life, Accident, or Health insurance upon which action was postponed, or certificate issued with increased premium or for an amount other than applied for, or upon which a Certificate was not issued, or later cancelled recalled or reinstated denied?
Yes    No 
11. Family record:
 
LIVING
DEAD
  Age State of Health     Age Year & Cause of Death
Spouse    
Father    
Mother    
Brothers    
Sister    
12. Remarks:
(Please give details of all "Yes" answers. Dates-Durations-Results-Doctor's names and addresses.)
 


PART II. DECLARATION OF INSURABILITY

  To proposed Insured age 16 and over and to payor proposed for payor benefits. Answers must be made and signed in the presence of a representative of the Federation.
(If your answer is "yes" to any questions, specify details in "Remarks".)
13. Height & Weight
Height
Weight
  A.   Are you in good health? Yes    No 
  B.   Have any of your family members including your parents, brothers or sisters had mental trouble, epilepsy, tuberculosis, cancer, diabetes or heart disease, or committed suicide? Yes    No 
14. Have you ever been told that you had any of the following diseases or ailments or received treatment for:
(If your answer is "yes" to any questions, specify details in "Remarks".)
  A.   Dizziness, fainting, convulsions, St. Vitus' Dance, sinus, headache, insomnia, fractured skull, concussion of brain, epilepsy, paralysis or stroke; mental or nervous disorder?
  Yes    No 
  B.   Chronic cough, spitting of blood, bronchitis, pleurisy, throat trouble, asthma, emphysema, allergies, advised to change residence for health reasons, tuberculosis or other respiratory disorder?
  Yes    No 
  C.   Chest pain, shortness of breath, high or low blood pressure, abnormal pulse, rheumatic fever, heart murmur, varicose veins, or any disorder of the heart or blood vessels, anemia or other disorder of the blood?
  Yes    No 
  D.   Indigestion, diarrhea, ulcer, appendicitis, blood in stool, gall bladder or liver disease, colitis, rectal disease, hernia or any abdominal disorder?
  Yes    No 
  E.   Sugar, albumin, blood or pus in urine; diabetes (used insulin); veneral disease (syphilis); stone or any disorder of kidney, bladder, prostate or reproductive organs?
  Yes    No 
  F.   Thyroid, or other endoctrine disorders?
  Yes    No 
  G.   Neuritis, sciatica, rheumatism, arthritis, gout or disorder of the muscles or bones, including the spine, back or joints?
  Yes    No 
  H.   Disorder of skin, lymph glands, cyst, tumor or cancer?
  Yes    No 
  I.   Excessive use of alcohol, tobacco or habit-forming narcotic drugs?
  Yes    No 
15. A.   Did you consult any physician, surgeon, or practitioner during the past five years for examination, treatment or surgery?
  Yes    No 
  State name, address of physician, dates of disease and result of treatment in "Remarks".
  B.   Have you ever been in a hospital, clinic, sanitarium or institution for observation or treatment?
  Yes    No 
  State name, address of place; specify disease and result of treatment in "Remarks".
  C.   Did you have an X-ray, electrocardiogram, blood, urine or other special test during the past five years for any ailment or disease?
  Yes    No 
  D.   Were you rejected, deferred or discharged by the armed forces for physical or mental condition?
  Yes    No 
  E.   Do you ever make aerial flights other than as fare-paying passenger on scheduled airlines, or contemplate any?
  Yes    No 
  F.   Did you ever apply for or receive a pension or disability benefit?
  Yes    No 
16. If your answer is "yes" to any questions, specify details in "Remarks".
  A.   To the best of your knowledge, are you pregnant now?
  Yes    No 
  B.   Have you ever had a menstrual disorder or been told that you have any tumor or disease of the breast or other female organs?
  Yes    No 
  C.   Have you ever had a miscarriage, difficult labor, stillborn, or Caesarian operation?
  Yes    No 
  D.   Have you passed the change of life?
  Yes    No 
  E.   Have you had any bleeding or discharge since?
  Yes    No 
  F.   Do you have any children?
  Yes    No 
(State number and specify any complications connected with pregnancies and birth in "Remarks".)


PART III. DECLARATION

20. The Applicant declares that to the best of his (her) knowledge and belief, the answers and statements made to the questions of Parts I and II are complete and true. The above answers were made to secure insurance applied for from the Federation. The Applicant agrees that if a medical application be required by the Medical Director of the Federation, the report of said examination will become a part of the Certificate issued by the Federation.
 
  Signature
Proposed Insured's Signature
Date