BROKERS

DECLARATION AND AGREEMENT - I/We have personally completed and reviewed all of my/our answers to the questions in this Application and represent that all information I/we have provided is true, complete, and correctly recorded. I/We understand that this information will be used to determine each person's eligibility for coverage under the Policy and any false statement or misrepresentation may result in loss of coverage or claim denial. The Applicant (and Spouse or Dependent if coverage elected) must be eligible based on the Company's rules in effect on the date of Application and on the Policy Effective Date. Policy coverage (or Reinstatement of coverage), if issued and approved by the Company, will become effective on the date recorded in the Policy Schedule of Benefits and not the date this Application is signed. I/We understand that no agent or producer can accept risks, modify policies, or waive any rights or requirements of the Company. If this Application is completed..

Primary location: Galveston United States