Guarantee Trust Life

Founded in 1936, Guarantee Trust Life (GTL) Insurance Company is a legal mutual reserve company located in Glenview, Illinois, which provides a portfolio of competitive health, accident, life, and special risk insurance programs.

Guarantee Trust Life Insurance Company offers a Whole Life Insurance product that helps protect your client’s family’s future. Where the premiums never increase, there is no medical exam needed, a simple application process, and whole life insurance accumulates cash value.

AUTHORIZATION TO RELEASE MEDICAL INFORMATION
I authorize Guarantee Trust Life Insurance Company (herein referred to as the “Company”), insurance support organizations, authorized representatives, and any reinsurers, to obtain information as to the diagnosis, treatment, or prognosis of my physical condition, other coverage and criminal or motor vehicle records needed to underwrite my application for insurance. Upon presentation of this Authorization, or a photocopy of it, the Company may obtain, without
restriction (except psychotherapy notes,) such information or records from any doctor, health professional, hospital, clinic, the Veterans Administration, insurance company, pharmacy benefit manager, pharmacies or pharmacy-related facility which have such information including any medical information provided to any affiliate insurance company on previous applications and medical information provided to our health division for underwriting or claim servicing purposes. The Company and its reinsurers may also obtain such information from MIB, Inc. I authorize the Company, or its reinsurers, to make a brief report of my personal health information to MIB, Inc. This Authorization includes all information about drugs, alcoholism, and mental 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.

Authorization for Electronic Delivery of Documents
I acknowledge receipt of the Consent for Use of Electronic Records and Electronic Signatures Disclosure, which describes the requirements for Electronic Policy Fulfillment and Communications, as well as my right to withdraw my consent for Electronic Records. Guarantee Trust Life Insurance Company will be held harmless for any claim, liability, loss or cost, when we have used reasonable procedures to confirm communications and transactions are authorized and genuine and those procedures have been followed.
 By checking this box, I authorize Guarantee Trust Life Insurance Company to provide the Electronic Delivery of Documents.
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 medical professional to get an organ transplant?

 Yes  No

  1. Have you ever been diagnosed with or treated by a medical professional for Alzheimer’s disease or dementia or are currently being treated for memory loss?  Yes  No
  2. Within the last twenty four months, have you been diagnosed as having, or been prescribed medication by a medical professional or been treated by a medical professional for cancer (excluding Stage A Prostate Cancer, Carcinoma in Situ, Squamous Cell or Basal Cell Carcinoma)?
     Yes  No
  3. Have you ever had or been recommended to have an amputation due to complications from diabetes?  Yes  No
  4. 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 told by a medical professional that you have less than 12 months to live?  Yes  No
  5. Have you been diagnosed by a medical professional as having the Human Immunodeficiency Virus (HIV), ARC or AIDS?  Yes  No
    SAMPLE APPLICATION
    Submit via e-App only
    3 ICC21-APPL1-21 (XH)

    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 presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

    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

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 confidential 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 file. In order to exercise these rights, you must contact us in writing requesting access or correction.

You have no access right to privileged information. If we used a “consumer reporting agency,” you have the right to: (1) ask to talk with them and (2) ask them about their report. You may write us for the name and address of the agency.

This paragraph is not intended as a complete description of your right of access and correction. If you would like a more complete description of our insurance information and Privacy Protection Practices, please write: Guarantee Trust Life Insurance Company, 1275 Milwaukee Avenue Glenview, IL 60025.

Part 2: Notification Regarding MIB, Inc.
Information regarding your insurability will be treated as confidential. Guarantee Trust Life Insurance Company or its reinsurers may, however, make a brief report thereon to MIB, Inc., a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If you apply to another member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, MIB,
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
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 equivalent of your handwritten signature.
*An active email address is not required for viewing and / or downloading a copy of your insurance coverage from GTL’s secure website.
GTL is required by law to provide you with the following information relative to (i) electronic delivery of disclosures, notices and other electronic communications (collectively, “Electronic Records”) and (ii) Electronic Signature.

Types of Electronic Records Covered by This Consent
Unless you request otherwise, documents that form our insurance relationship will be provided to you electronically. Electronic Records include, but are not limited to:
• Application(s) and related forms
• 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.

SAMPLE APPLICATION
Submit via e-App only
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
You may elect to withdraw your consent for Electronic Records at any time by contacting us in writing, by phone, or through the Policyholder – Customer Service link on GTL’s website. Please see the Company Contact Information below.

Company Contact Information

  1. Write us at…
    Guarantee Trust Life Insurance Company
    ATTN: Policyholder Service
    1275 Milwaukee Avenue
    Glenview, IL 60025
  2. 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.

Replacement Form (If Applicable)
GUARANTEE TRUST LIFE INSURANCE COMPANY
1275 Milwaukee Avenue • Glenview, Illinois 60025
NOTICE TO APPLICANTS REGARDING REPLACEMENT OF
LIFE INSURANCE OR ANNUITYTHIS NOTICE IS FOR YOUR BENEFIT AND IS REQUIRED BY LAW

  1. If you are urged to purchase life insurance and surrender, lapse, or in any way change the status of existing life insurance, the agent is required to give you this notice.
  2. It may not be advantageous to drop or change existing life insurance in favor of new life insurance, whether issued by the same or a different insurance company. Some of the disadvantages are:

a. The amount of the annual premium under an existing policy maybe lower than that under a new policy having the same or similar benefits.
b. Generally, since the initial cost of life insurance policies are charged against the cash value increases in the earlier policy years, the replacement of an old policy could result in the policyholder sustaining the burden of these costs twice.
c. The incontestable and suicide clauses begin anew in a new policy. This could result in a claim under a new policy being denied by the company which would have been paid under the old policy.
d. Existing policies may have more favorable provisions than new policies in such areas as settlement options and disability benefits.
e. An existing policy may have a reserve value in addition to any cash value which may be of some benefit to the insured.
f. The insurance company carrying your current insurance policy can often make a desired change on terms which would be more favorable than if existing insurance is replaced with new insurance.

  1. It may not be advantageous to change an existing policy to reduced paid-up or extended term insurance or to borrow against its loan value beyond your expected ability or intention to repay in order to obtain funds for premiums on a new policy.
  2. There may be a situation in which a replacement policy is advantageous. You may want to receive the comments of the present insurance company before deciding this important financial matter.

I hereby acknowledge that I received the above “Notice to Applicants Regarding Replacement of Life Insurance or an Annuity” before I signed the application for the proposed new insurance.
Date
STATEMENT BY APPLICANTS REGARDING REPLACEMENT
OF LIFE INSURANCE TO THE REPLACED INSURER
I have read the ‘NOTICE TO APPLICANTS REGARDING REPLACEMENT OF LIFE INSURANCE OR AN ANNUITY” which was furnished to me by the agent taking the application for this policy.
Please notify my present insurer(s) regarding this transaction.
The signature of the applicant shall be that of the insured unless someone other than the insured is the owner of the policy. If someone other than the insured is the owner of the policy, the owner must sign. If the insured is under eighteen (18) years of age, the parent is deemed to be the owner of the policy.
Certification by the agent:
I hereby certify that nothing was said or done during the sales presentation to influence the decision of the applicant regarding this statement.
Insurance Agency or Agent License Number
REPLACEMENT LIFE INSURANCE POLICY OR ANNUITY
DEFINITIONS FOR APPLICANT
Premiums: Premiums are the payments you make on the life insurance or annuity contract. They are unlike deposits in a savings or investment program because if you drop the policy you might get back less than you paid in.
Cash Surrender: This is the amount of money you can get if you surrender your life insurance policy or annuity. If there is a policy loan, the cash surrender value is the difference between the cash value printed in the policy and the loan value. Not all policies have cash surrender values.
Lapse: A life insurance policy may lapse when you do not pay the premiums within the grace period. If your policy had a cash surrender value, the insurer might change your policy to as much extended term insurance or paid-up insurance as the cash surrender value will buy. Sometimes the policy lets the insurer borrow from the cash surrender value to pay the premiums.
Surrender: You surrender a life insurance policy when you either let it lapse or tell the company you want to drop it. If a policy has a cash surrender value, you can receive such value in cash if you return the policy to the company with a written request.
Place on Extended Term: This means you use your cash surrender value to change your insurance to term insurance with the same insurer. In this case, the net death benefit will be the same as before but you will only be covered for a specified period of time.
Borrow Policy Loan Values: If your life insurance policy has a cash surrender value, you can usually borrow all or part of said amount from the insurer. Interest will be charged according to the terms of the policy, and if the loan and unpaid interest ever exceeds the cash surrender value the policy will be terminated. If you die, the amount of the loan and any unpaid interest due will be subtracted from the death benefits.
Evidence of Insurability: This means proof that you are an acceptable risk. You have to meet the standards of the insurer regarding age, health, occupation, and such other standards as the insurer feels necessary to be eligible for coverage.
Incontestable Clause: This says that after one (1) or two (2) years, according to the provisions of the contract, the insurer shall not resist a claim because you made a false or incomplete statement when you applied for the policy. During the first two (2) years if there are false or incomplete answers on the application and the insurer discovers them, the insurer can deny a claim as if the policy has never existed.
Suicide Clause: This says that if you commit suicide after being insured for less than two (2) years, your beneficiaries will receive only a refund of the premiums that were paid.

GTL Heritage Plan Whole Life Highlights:
Easy eApplication Process Simply fill out the application. There is no need for a medical exam or lengthy process.
Guaranteed Premiums Insured’s premium cannot be changed due to declining health. Heritage Plan premiums will remain the same as long as coverage is in force.
Guaranteed Benefits Insured’s can be sure that as long as premiums are paid, coverage will never be changed or canceled.
GTL Heritage Plan Graded Whole Life Highlights:
Issue Ages – 40-90 years
Expires at what age: Never expires (as long as premiums are paid)
Death Benefit Amounts – $2,500 to $25,000
Death Benefit in year 1 is Premiums Paid plus 5%
Death Benefit in year 2 is 50% of the face amount
Death Benefit after 2 years 100% of the face amount
GTL will pay the full face amount on accidental death in year 1 and year 2 under the Temporary Accidental Death Benefit.

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