INSURER'S STATEMENT AND APPLICATION FOR INSURANCE

I understand that:

"You" or "Your" means the member and the joint insured (if applicable). Credit Insurance is voluntary and not required in order to obtain this loan. You may select any insurer of your choice. You can get this insurance only if you check "yes" and sign your name and write in the date. The rate you are charged for the insurance is subject to change. You will receive written notice before any increase goes into effect. You have the right to stop this insurance by notifying your credit union in writing. Your signature means you agree that: If you elect insurance, you authorize the credit union to add the charges for insurance to your loan each month. You are eligible for disability insurance only if you are working for wages or profit for 25 hours a week or more on the date of any advance. If you are not, that particular advance will not be insured until you return to work. If you are off work because of temporary layoff, strike, or vacation, but soon to resume, you will be considered at work. You are eligible for insurance up to the Maximum Age for Insurance. Insurance will stop when you reach that age.

App. 821-0786

NOTE: The Life and Disability Insurance contains certain benefit exclusions, including a preexisting condition exclusion. Please refer to your certificate for details.

I apply for the following Credit Insurance coverage on: (Check yes or no)

CREDIT LIFE INSURANCE ALL LOAN AND VISA ACCOUNTS

Primary Insurer or Applicant
Primary Insure Only:

Yes No

CREDIT DISABILITY INSURANCE

Primary Insure Only:
Yes No
Primary Insurer and Applicant:
Yes No

I authorize the Credit Union to add the cost of my Credit Insurance to the amount of each insured Loan and Visa Account at the end of the appropriate billing period.

Applicant's Legal Signature

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Coapplicant's Legal Signature

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