For the purpose of obtaining the insurance coverage that I have requested, I hereby authorize Advisor Insurance Solutions (the "Representative”) and its affiliated agencies, to disclose my personal financial and health information to the insurance companies listed at the bottom of this page and to insurance agents and brokers acting on my behalf with respect to obtaining such insurance coverage.
I authorize any: person licensed to provide health care services, hospital, clinic or other medical or medically related facility, insurer, reinsurer, insurance support organization, the Medical Information Bureau, Inc., consumer reporting agency, state motor vehicle agency, employer, or any other person or institution to release to: each of the companies listed below, as well as to their reinsurers, any insurance support organizations, and those persons authorized to represent them, and the Apollon Insurance Group; any information related to my mental and physical health, lab results, other insurance coverage, hazardous activities, character, general reputation, finances, occupation, other personal traits, drug and/or alcohol use and driving record for me and my minor children who are to be insured. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases.
By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization and I instruct any physician, health care professional, hospital, clinic, medical facility, or other health care provider to release and disclose my entire medical record without restriction.
I understand that my insurance agent, the companies listed below, and their re‐insurers will use this information to help determine my eligibility for insurance and they may discuss and disclose this information with each other in helping determine my eligibility. The insurance agent may also use this information to help update and improve my insurance program.
I agree that the above‐named parties may also disclose my information to other insurers, reinsurers, Express Imaging Services, Inc., the Medical Information Bureau, Inc., and other persons or organizations performing business or legal services in connection with the underwriting process, or as may be otherwise lawfully required.
This authorization shall be valid for twelve (12) months from the date electronically signed. A copy of this authorization shall be as valid as the original. I understand that I am entitled to receive a copy of this authorization.
I understand that I may write to the Representative to revoke this authorization and that the revocation will take effect when the Representative receives my written request. I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. I also understand that, to the extent that other law allows an insurance company listed below to contest a claim under an insurance policy or the insurance policy itself, my revocation of this authorization may not be effective.
I understand that if I refuse to sign this authorization, the Representative may not be able to provide full and complete information about the insurance coverage and its cost that may be available to me. I also understand and acknowledge that each of the insurers listed on this form, or to which I may formally apply, may require me to sign a similar authorization used exclusively by such insurer before they will process my application or offer insurance coverage. I understand that my refusal to sign this authorization will not affect my ability to obtain treatment or payment for services, or my eligibility for health care benefits; provided, however, that if a health care service (e.g, a physical exam) is requested solely for the purpose of creating protected health information to be disclosed to a third party, the health care provider may refuse to provide the service if I do not sign this authorization.
American General Life Insurance
Company/Corbridge Financial, American National Insurance Companies, AXA Equitable Life Insurance
Company, Global Atlantic, Accordia Life, Banner Life Insurance Company, John Hancock, Legal
& General America, Lincoln Financial Group, MassMutual Financial Group, Minnesota Life Insurance, Mutual of Omaha Insurance
Companies, Nationwide Life, One America, Pacific Life, Principal Life
Insurance, Principal National Life, Protective Life Insurance Company,
Prudential Insurance Company of America, Pruco Life Insurance Company, Pruco
Life Insurance Company of New Jersey, SBLI, Symetra Life Insurance Company,
Transamerica Life Insurance Company, United of Omaha Life Insurance Company,
United States Life Insurance Company in the City of New York, William Penn Life
Insurance Company of New York, Zurich, New York Life, Allianz Life, Cincinnati
Life, Securian Life