Royal Neighbors Documentation
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ICC141720-N Rev. 7-2014
A Fraternal Benefit Society
Incorporated in 1895
Royal Neighbors of America
Home Office
230 Sixteenth St.
Rock Island, IL 61201
(800) 627-4762
(309) 788-4561
www.royalneighbors.org
IMPORTANT INFORMATION – FOR USE WITH APPLICATIONS COMPLETED BY TELEPHONE
This document contains important consumer disclosure notices and application agreements, acknowledgments, and authorizations.
The applicant must read this document prior to completing the application and must retain a copy for their records.
During the telephonic interview process, the proposed insured will be asked to acknowledge and agree to the terms of this document,
which includes the Authorization, MIB, Inc. Notice, Fair Credit Report Act Notice, Agreement/Acknowledgement, and Fraud Notice
Warning below. These items will become part of the application completed and signed by the proposed insured.
Consumer Disclosure Notices
FRAUD NOTICE/WARNING: 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.
MIB, Inc., Notice Information regarding your insurability will be treated as confidential. Royal Neighbors of America (Royal Neighbors) or its reinsurers may make a brief report thereon to the MIB, Inc., formerly known as Medical Information Bureau, a not-for-profit membership organization of insurance companies which operates an information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance coverage, or if a claim for benefits is submitted to such company, MIB,
upon request, will supply such company with the information in its file. Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your file. Please contact MIB at (866) 692-6901, TTY (866) 346-3642. If you question the accuracy of information in MIB’s file, you may contact MIB and seek a correction in accordance with the procedures set forth in the federal Fair Credit Report Act. The address of MIB’s information office is: MIB, 50 Braintree Hill Park, Suite 400, Braintree, MA 02184.
Royal Neighbors or its reinsurers may also release information in its file to other insurance companies to whom you apply for life or health insurance, or to whom a claim for benefits may be submitted. Information for consumers about MIB may be obtained on its website at www.mib.com.
Fair Credit Report Act Notice
This is to inform you that as part of our underwriting procedures in connection with this application, an investigative consumer report may be obtained on the Proposed Insured. This report will provide applicable information concerning character, general reputation, personal characteristics, and mode of living.* This information will be obtained through personal interviews with neighbors, friends, and associates. You may request to be interviewed in connection with the preparation of the investigative consumer report. You have
the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation. No information collected concerning the sexual orientation of the Proposed Insured will be used to determine her or his eligibility for life insurance.
*Information obtained will not be used to determine sexual orientation.
ICC141720-N Rev. 7-2014
Application Agreements, Acknowledgments, and Authorizations
Agreement/Acknowledgement
Agreement/Disclosure: To the best of my knowledge and belief, all statements in my application for life insurance including any amendments and supplements are true and complete. I also agree that:
• My statements in the application and any amendment(s), paramedical/medical exam, and supplement(s) are the basis of any certificate issued and will be attached to and, along with the articles of incorporation and bylaws of Royal Neighbors, become part of the new certificate.
• No information will be deemed to have been given to Royal Neighbors unless it is stated in the application and amendment(s), paramedical/medical exam, and any supplement(s).
• Only authorized officers of Royal Neighbors may: a) make or change any contract of insurance; b) make a binding promise about insurance; or c) change or waive any term of an application, receipt, or certificate.
• If not a current member, I, the Proposed Insured, hereby apply to become a member of Royal Neighbors as indicated by my signature on the application. As a member, I agree to uphold the principles of Faith, Unselfishness, Courage, Endurance, and Humility upon which Royal Neighbors was founded more than 100 years ago.
Authorization
I, the Proposed Insured, hereby authorize any licensed physician, medical practitioner, hospital, clinic, laboratory, pharmacy, pharmacy benefit manager, or other medical facility, insurance or reinsurance company, MIB, Inc., consumer reporting agency, division of motor vehicles, the veterans administration, or other government agency or department having information as to the diagnosis, treatment, or prognosis with respect to any physical or mental condition, or having any non-medical information, concerning me to release and disclose the entire medical record and any other protected health or other information concerning me
within the past 10 years, without restriction, to Royal Neighbors, its agents, employees, or representatives. I further authorize Royal Neighbors, or its reinsurers, to make a brief report of my personal health information to MIB. This includes information on the treatment of alcohol, drug, and tobacco abuse, and psychiatric diagnosis and treatment. In order to facilitate the rapid transmission of such information, I authorize all the sources named above, except MIB, to give such information to any legal representative or agent employed by Royal Neighbors.
I understand that the protected information is to be disclosed under this authorization so that Royal Neighbors may underwrite my application for life insurance, determine my eligibility for insurance, risk rating, or certificate issuance determinations, administer claims and determine or fulfill responsibility for coverage and provision of benefits, administer coverage, and conduct other legallypermissible activities that relate to any coverage I have applied for with Royal Neighbors. Any protected information obtained will not
be released by Royal Neighbors to any person or organization EXCEPT to other divisions and/or departments of Royal Neighbors, MIB, other life/health insurance organizations or fraternal benefit societies with which I have insurance contracts or to whom I may apply for insurance or to whom a claim for benefits may be submitted, or other persons or organizations performing business or legal services in connection with my application, insurance certificate(s), or claim for benefits or as may be otherwise lawfully required or
as I may further authorize.
I understand that this authorization shall remain in force for 24 months from the date signed if used in connection with an application for life insurance certificate, an application for reinstatement of a life insurance certificate, or a request for change in certificate benefits; or for the duration of a claim if used for the purpose of collecting information in connection with a claim for benefits under a certificate.
I understand and agree that a copy of this authorization is as valid as the original and that I or my authorized representative is entitled to receive a copy. I understand that this authorization may be revoked by me at any time in writing, and if I refuse to sign or if I subsequently revoke this authorization, Royal Neighbors may not be able to process this application, and if coverage has been issued, may not be able to process any benefit payments. I agree that Royal Neighbors shall be fully protected if it acts in reliance on this authorization prior to receiving notice of revocation at its Home Office or to the extent that Royal Neighbors has a legal right to contest a claim under an insurance contract. Any information that is disclosed pursuant to this authorization may be re-disclosed as provided herein or as required or authorized by law and may then no longer be covered by federal rules governing privacy and confidentiality of health information.
NO IMMEDIATE LIFE INSURANCE COVERAGE: Royal Neighbors will have no liability under this application unless and until: a) it has been received and approved by Royal Neighbors at its Home Office; b) the certificate has been issued and delivered to the certificatowner; c) the first premium has been paid to and accepted by Royal Neighbors (If the first premium is to be electronically drafted, then the premium has not been “paid” until honored by the financial institution.); and d) at the time of delivery and payment,
the facts concerning the insurability of the Insured are as stated in this application.
The proposed insured’s signature will appear at the end of the application for insurance, directly below this Authorization.
MEMBER BENEFITS
• DENTAL DISCOUNTS* • In most instances, members save 20% to 40% on most dental procedures including routine oral exams, x-rays, crowns, fillings, and major work such as dentures, root canals, and crowns at participating dental locations.
• VISION DISCOUNTS* • Members save 10% to 60% off the retail price of eyewear, plus discounts on exams from more than 20,000 providers nationwide including independent optometrists, ophthalmologists, opticians, and leading optical retailers. Members save 40% to 50% off the overall national average cost of LASIK surgery.
• DISCOUNT LAB TESTING* • Members have access to over 1,500 major clinical laboratories nationwide where they can save 10% to 80% on typical costs for lab work.
• DISCOUNT LEGAL SERVICES* • Get legal answers from experienced lawyers at discounted rates. Attorneys help with traffic tickets, bankruptcy, divorce, and spousal and child support.
• MRI & CT SCANS* • Members can save from 40% to 75% on usual charges for MRI, CT Scans, and Ultrasounds at thousands of credentialed radiology centers nationwide.
• PRESCRIPTION DISCOUNTS* • Members have access to savings from 10% to 85% on most prescriptions at thousands of pharmacy locations nationwide.
• HEARING AIDS AND SERVICES* • Save on hearing aids – Amplifon helps members find the right hearing aid solution to fit their lifestyle through personalized service and exceptional products for every budget. E X C L U S I V E M E M B E R B E N E F I T S AWAIT YOU Member benefits are provided at the discretion of Royal Neighbors of America and are not available in all states. They are not part of any insurance or annuity contract and are not guaranteed. Insurance or annuity products should not be purchased for eligibility or maintenance of nonguaranteed membership benefits. These products should only be purchased if they meet the financial needs of the applicant. Member benefits are available at no extra cost.
• DENTAL DISCOUNTS* • In most instances, members save 20% to 40% on most dental procedures including routine oral exams, x-rays, crowns, fillings, and major work such as dentures, root canals, and crowns at participating dental locations.
• VISION DISCOUNTS* • Members save 10% to 60% off the retail price of eyewear, plus discounts on exams from more than 20,000 providers nationwide including independent optometrists, ophthalmologists, opticians, and leading optical retailers. Members save 40% to 50% off the overall national average cost of LASIK surgery.
• DISCOUNT LAB TESTING* • Members have access to over 1,500 major clinical laboratories nationwide where they can save 10% to 80% on typical costs for lab work.
• DISCOUNT LEGAL SERVICES* • Get legal answers from experienced lawyers at discounted rates. Attorneys help with traffic tickets, bankruptcy, divorce, and spousal and child support. • MRI & CT SCANS* • Members can save from 40% to 75% on usual charges for MRI, CT Scans, and Ultrasounds at thousands of credentialed radiology centers nationwide.
• PRESCRIPTION DISCOUNTS* • Members have access to savings from 10% to 85% on most prescriptions at thousands of pharmacy locations nationwide.
• HEARING AIDS AND SERVICES* • Save on hearing aids – Amplifon helps members find the right hearing aid solution to fit their lifestyle through personalized service and exceptional products for every budget. E X C L U S I V E M E M B E R B E N E F I T S AWAIT YOU Member benefits are provided at the discretion of Royal Neighbors of America and are not available in all states. They are not part of any insurance or annuity contract and are not guaranteed. Insurance or annuity products should not be purchased for eligibility or maintenance of nonguaranteed membership benefits. These products should only be purchased if they meet the financial needs of the applicant. Member benefits are available at no extra cost. • DISCOUNTS • The Royal Neighbors Discount Program offers access to over 100,000 discounts and provides members an elite collection of local and national discounts from thousands of retailers, fitness centers, attractions, and events through Abenity.
• LIFE LINE SCREENING* • We’ve partnered with Life Line Screening to offer members non-invasive tests at a discounted rate to learn if they are at risk for vascular disease.
• SCHOLARSHIPS • Since 1961, we have offered scholarships to our beneficial members—those who are insured and/or own an annuity with Royal Neighbors. Scholarships are offered for both traditional and non-traditional students.
• MEMBER RELIEF FUND • Financial assistance may be available to beneficial members—those who are insured and/or own an annuity with Royal Neighbors, who are experiencing extreme financial hardship as a result of illness, accident, or natural disaster.
• THE ROYAL NEIGHBOR MAGAZINE • The Royal Neighbor, our quarterly publication offers informative articles designed to help members stay healthy, both physically and financially, as well as updates on Royal Neighbors news and programs.
• NATION OF NEIGHBORS SM • Our signature program to empower women has awarded more than $1.8 million to help individuals reach their goals and live their dreams. The program is designed to provide financial assistance to individuals who have a plan to start or expand a business or an organization/group that helps women and girls.
• VOLUNTEER OPPORTUNITIES • Our members have been making a difference in their local communities for over 122 years. Our neighbor-helping-neighbor philosophy encourages members to work together and give back to their communities.
• VOTING PRIVILEGES • Adult beneficial members have a direct voice in the governance of the organization by voting for the Royal Neighbors Board of Directors. Member benefits are provided at the discretion of Royal Neighbors of America and are not available in all states. They are not part of any insurance or annuity contract and are not guaranteed. Insurance or annuity products should not be purchased for eligibility or maintenance of nonguaranteed membership benefits. These products should only be purchased if they meet the financial needs of the applicant. Member benefits are available at no extra cost. *The health discount programs are not insurance and not intended to replace health insurance. Services administered by New Benefits, Ltd. Form 182-A; Rev. 5-2017
• DISCOUNTS • The Royal Neighbors Discount Program offers access to over 100,000 discounts and provides members an elite collection of local and national discounts from thousands of retailers, fitness centers, attractions, and events through Abenity.
• LIFE LINE SCREENING* • We’ve partnered with Life Line Screening to offer members non-invasive tests at a discounted rate to learn if they are at risk for vascular disease.
• SCHOLARSHIPS • Since 1961, we have offered scholarships to our beneficial members—those who are insured and/or own an annuity with Royal Neighbors. Scholarships are offered for both traditional and non-traditional students.
• MEMBER RELIEF FUND • Financial assistance may be available to beneficial members—those who are insured and/or own an annuity with Royal Neighbors, who are experiencing extreme financial hardship as a result of illness, accident, or natural disaster.
• THE ROYAL NEIGHBOR MAGAZINE • The Royal Neighbor, our quarterly publication offers informative articles designed to help members stay healthy, both physically and financially, as well as updates on Royal Neighbors news and programs. • NATION OF NEIGHBORS SM • Our signature program to empower women has awarded more than $1.8 million to help individuals reach their goals and live their dreams. The program is designed to provide financial assistance to individuals who have a plan to start or expand a business or an organization/group that helps women and girls.
• VOLUNTEER OPPORTUNITIES • Our members have been making a difference in their local communities for over 122 years. Our neighbor-helping-neighbor philosophy encourages members to work together and give back to their communities.
• VOTING PRIVILEGES • Adult beneficial members have a direct voice in the governance of the organization by voting for the Royal Neighbors Board of Directors. Member benefits are provided at the discretion of Royal Neighbors of America and are not available in all states. They are not part of any insurance or annuity contract and are not guaranteed. Insurance or annuity products should not be purchased for eligibility or maintenance of nonguaranteed membership benefits. These products should only be purchased if they meet the financial needs of the applicant. Member benefits are available at no extra cost. *The health discount programs are not insurance and not intended to replace health insurance. Services administered by New Benefits, Ltd. Form 182-A; Rev. 5-2017
INSURING LIVES SUPPORTING WOMEN SERVING COMMUNITIES'”
230 16th Street • Rock Island, IL 61201 (309) 788-4561 • (800) 627-4762 contactroyalneighbors.org • www.royalneighbors.org
Accelerated Living Benefit Rider Disclosure For use with Rider Form Series 1766
IF ROYAL NEIGHBORS OF AMERICA MAKES AN ACCELERATED BENEFIT PAYMENT, A LIEN WILL BE ESTABLISHED AGAINST THE CERTIFICATE TO WHICH THIS RIDER IS ATTACHED. DEATH BENEFITS, CASH VALUES, AND LOAN VALUES WILL BE REDUCED IF AN ACCELERATION-OF-LIFE-INSURANCE BENEFIT IS PAID.
PREMIUMS — There are no premiums charged for this rider. If the certificate to which the rider is attached requires regularly scheduled premiums, scheduled premium payments must be made to keep the certificate in force. If the premiums due are not paid and the certificate enters a grace period, the rider will be subject to all provisions of the certificate.
AN ACCELERATED LIFE INSURANCE BENEFIT MAY BE TAXABLE — The acceleration of life insurance benefits offered under this rider is intended to qualify for favorable tax treatment under the Internal Revenue Code. If the acceleration of life insurance benefits qualifies for such favorable tax treatment, the benefits will be excludable from your income and not subject to federal taxation. Whether such benefits qualify depends on factors such as the Insured’s life expectancy at the time the benefits are accelerated and whether the accelerated benefits are used to pay for necessary long-term care expenses, such as nursing home care. Tax laws relating to the acceleration of life insurance benefits are complex. You are advised to consult with a qualified tax professional regarding the circumstances under which you might be able to receive an acceleration of a life insurance benefit, excludable from income under federal law.
Receipt of an acceleration of life insurance benefits may also affect your, your spouse, or family’s eligibility for public assistance programs such as medical assistance (Medicaid), Aid to Families with Dependent Children (AFDC), Supplementary Social Security Income (SSI), and drug assistance programs. You are advised to consult with a qualified tax professional and with social service agencies regarding how receipt of such accelerated benefits may affect your, your spouse, and your family’s eligibility for public assistance.
BENEFIT — The Accelerated Living Benefit Rider provides for a single lump sum payment of an accelerated life insurance benefit using a portion of your life insurance certificate’s death benefit. Eligible proceeds are equal to 75% of the certificate’s death benefit in force on the day Royal Neighbors receives the acceleration request, up to a maximum of $250,000. A minimum amount of at least $5,000 must be requested. Only one acceleration for an insured will be allowed.
This benefit is paid to the Owner of the life insurance certificate while the insured is living, provided the insured is diagnosed with a qualified terminal condition with a life expectancy of twelve (12) months or less, or the insured is permanently confined to a qualified nursing home, as provided under the terms of the rider. Royal Neighbors of America will require satisfactory evidence and a physician’s statement certifying the insured’s life expectancy in the event of a terminal condition; or, certification of permanent confinement in a qualified nursing home.
If the insured dies before the accelerated payment is made, the death benefit payable under the certificate will be paid to the beneficiary.
EFFECT OF ACCELERATION OF A BENEFIT — The accelerated benefit payment, administrative fee, and accrued interest constitute a lien on the life insurance certificate. Benefits payable at the death of the insured, and any cash or loan values available under the certificate will be reduced by any outstanding lien balance. At the time the accelerated benefit is paid, Royal Neighbors will provide the owner of the certificate with a statement specifying: 1. the amount of the accelerated benefit paid; 2. the effect of the accelerated benefit payment on the certificate’s face amount, cash value, future premiums, loans and liens.
Form 1767-TX; Rev. 7-2006
Page 1 of 3
LIEN OF ACCELERATED BENEFIT — Royal Neighbors reserves the right to charge an administrative fee of $150, if allowed by law. The amount of the administrative fee will be deducted from the Accelerated Benefit payment.
Interest on the amount of the Accelerated Benefit and the administrative fee will accrue from the date Royal Neighbors pays the Accelerated Benefit to the date of the Insured’s death, and shall constitute a lien on the certificate. At the time of the Insured’s death, the Death Benefit will be reduced by the amount of the Accelerated Benefit plus the accrued interest, the amount of any outstanding loans, and past due premiums, if any.
The interest rate applied to the Accelerated Benefit and the administrative fee shall be as set by Royal Neighbors and in effect at the time of payment of the Accelerated Benefit, but will not exceed the certificate loan interest rate stated in the certificate.
The Owner may only withdraw any portion of the certificate’s cash value or obtain a loan on any portion of the certificate’s loan value which exceeds the amount of the lien of the Accelerated Death Benefit, and any outstanding certificate loans, or reserve impairments, if any.
ELIGIBILITY — The Owner of the certificate to which this rider is attached is not eligible for payment of the accelerated benefit under this rider if: ¦ the Owner is required, by law, to use any payment to meet the claims of creditors, whether due to bankruptcy or otherwise; or ¦ the Owner is required by a government agency to use the payment in order to apply for, obtain, or keep a government benefit or entitlement; or ¦ the certificate to which this rider is attached is subject to any restriction imposed by any court order or rule of law; or ¦ the certificate to which this rider is attached has been continued as Extended Term Insurance (ETI) or as a Reduced Paid Up certificate (RPU).
COLLATERAL ASSIGNEES AND IRREVOCABLE BENEFICIARIES — Collateral assignees and irrevocable beneficiaries must sign a written consent to the payment of an accelerated benefit before such payment may be made to the Owner of the certificate. The written consent must be received at the Home Office in a form acceptable to Royal Neighbors of America before the date the accelerated benefit is paid.
TERMINATION — This rider will terminate and cease to be in force at the earliest of the following: 1. when the certificate to which it is attached terminates. 2. when a non-forfeiture option is elected. 3. on any date by prior written request of the Owner in proper form. Return of the certificate to the Home Office for proper endorsement may be required.
The certificate, to which this rider is attached, will terminate at any time the indebtedness, including any lien balance and certificate loans and reserve impairments, if any, plus accrued interest, exceeds the certificate’s Death Benefit.
ASSIGNMENT — The Owner may not assign this rider or the Accelerated Benefit payments made under this rider.
FILING A CLAIM — Royal Neighbors will pay the Owner the benefits due under the Accelerated Living Benefit Rider upon receipt of a written request from the Owner, and due proof at the Owner’s expense that the Insured has been diagnosed with a qualified terminal condition, or permanently confined to a qualified nursing home, pursuant to the terms of the rider. Due Proof includes, but is not limited to, a statement signed by a licensed physician that the Insured has been diagnosed with a qualified terminal condition, or is permanently confined to a qualified nursing home. Royal Neighbors of America reserves the right to require, at Royal Neighbors’ expense, an exam by a physician of Royal Neighbors’ choice in order to confirm that the Insured has a qualified condition or confinement, and to request documents that support the qualified condition diagnosis from the Insured’s attending physician.
Form 1767-TX; Rev. 7-2006
Page 2 of 3
SAMPLE ILLUSTRATION — The sample illustration below assumes: (1) a $100,000 death benefit; (2) that there are no outstanding loans on the certificate; (3) the entire available accelerated benefit is paid; (4) the interest rate on the lien is 8% per annum; and (5) the administrative fee is $150.
Before payment of the accelerated benefit
Certificate Death Benefit $100,000
Available Accelerated Benefit (lesser of 75% of certificate face or $250,000) $ 75,000Accelerated Benefit Payment $ 75,000
Initial Lien Amount on Certificate $ 75,000
LESS — Administrative Fee $ 150
Net Payment to the Owner $ 74,850
If Death Occurs Immediately After Accelerated Benefit Is Paid Certificate Death Benefit $100,000
LESS — Initial Lien Amount $ 75,000 Net Death Proceeds Payable At Death Of The Insured $ 25,000
If Death Occurs Six (6) Months After Accelerated Benefit Is Paid Certificate Death Benefit $100,000
LESS — Initial Lien Amount $ 75,000
LESS — Accrued Interest on the Lien Amount $ 2,943
Net Death Proceeds Payable At Death Of The Insured $ 22,057
Form 1767-TX; Rev. 7-2006
Page 3 of 3
