Single Premium Life Insurance Application With Assignment Single Premium Individual Life Insurance Application With Assignment PROPOSED INSURED/ANNUITANT INFORMATION Proposed Insured Social Security Number Street Address Telephone City State Zip Code Date of Birth: Age: Sex Male Female OWNER INFORMATION Owner Name, if other than Proposed Insured Social Security Number Street Address Telephone City State Zip Code Relationship Date of Birth: Age: Sex Male Female ASSIGNMENT INFORMATION Assignment: I hereby assign to all of the benefits being applied for. Such assignment is Revocable Irrevocable Street Address City State Zip Code Telephone REPLACEMENT INFORMATION Does the Proposed Insured have existing Life Insurance or an Annuity Policy? Yes No Is the policy applied for intended to replace any existing Life Insurance or Annuity Policy? Yes No BENEFICIARY INFORMATION Primary’s Name Relationship Percentage Street Address City State Zip Code Telephone Email Contingent’s Name Relationship Percentage Street Address City State Zip Code Telephone Email COVERAGE AND PREMIUM PAYMENT INFORMATION Total Amount of Insurance Amount of Premium Amount of Premium All premium checks must be payable to American Century Life. Do not make checks payable to the agent or leave the payee’s name blank. REPRESENTATIONS AND SIGNATURES I represent that all statements and answers contained in this Application are full, complete and true as written and correctly recorded. I understand that a material misrepresentation, untrue declaration, or failure to disclose all material facts may result in loss or cancellation of coverage. I agree: (1) this Application and any contract issued on it shall constitute the entire contract of insurance; (2) no person other than the President or Secretary of the Company can act for it or make, modify or discharge any part of the contract or waive any of the Company’s rights and requirements; and (3) No coverage will start unless: (i) a policy is issued; (ii) the policy is accepted; and (iii) the first full premium is paid while all persons to be covered are living and their health remains as stated in this Application. I understand that a copy of this Application will serve as receipt for the amount paid. WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Signature of Proposed Insured Date Name of Insured Signature of Parent or Guardian (if Proposed Insured is a Minor) Date Signature of Owner (if applicable) Date Signature of Agent Date Name of Agent Agent Number Send
