Accidental Death Application
Choose your benefit level
Please correct pre-filled information as necessary
Note: You must be between 18 to 69 years of age on the date the insurance becomes effective, to be eligible for this coverage. I wish to authorize the Accidental Death Insurance I have selected above to be issued to me, by Farmers New World Life Insurance Company, 3120 139th Avenue SE, Suite 300, Bellevue, WA 98005 (the ‘Company’). I understand that coverage will take effect following receipt of this application and payment of the first premium via the payment method I have indicated below. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance, is guilty of a crime and may be subject to fines and confinement in prison.
TERMS AND CONDITIONS
CONSENT FOR ELECTRONIC DELIVERYFarmers New World Life Insurance Company (“FNWL”) and its subsidiaries and affiliates (collectively, “Farmers”) are pleased to offer electronic delivery (“E-Delivery”) of notices and documents applicable to your selected insurance policies. Only those policies that you have selected will be enrolled for this service. Please read this consent form carefully. By electing to enroll in our E-Delivery option, you agree to be bound by its terms and conditions. If you do not agree with any of these terms and conditions, you may not enroll in E-Delivery. By consenting to E-Delivery, you are acknowledging and agreeing to the following:• To receiving all available notices and documents applicable to your selected insurance policies, including but not limited to prospectuses, supplements to prospectuses, annual and semi-annual reports, annual statements, privacy statements, quarterly reports, proxy statements, special announcements, declaration pages, endorsements and policy contracts (collectively, “E-Delivery Documents”) via electronic delivery. There may be some documents that we cannot deliver electronically due to legal and or technological constraints in your state. These documents will be delivered to you via United States Postal Service (USPS) to your postal address.• That E-Delivery Documents will be delivered in PDF or HTML format, and that you have an email account, access to an Internet browser and Adobe Acrobat Reader (Acrobat software is available for download free of charge at www.adobe.com®). If you wish to print documents, you must also have access to a printer.• As E-Delivery Documents become available, we will electronically deliver to the e-mail address provided by the policy owner. We will only deliver materials to the policy owner.• That you will maintain a current email address with Farmers and ensure that it is active and capable of receiving new emails. To do this, ensure that your e-mail account has sufficient space for new e-mails and that your e-mail server and spam-blocking software do not block our e-mails. We are not responsible for problems arising from e-mails sent to an inactive or out-of-date e-mail address, unless we are solely negligent for using an incorrect address. If an email is returned to us as undeliverable, paper copies of policy documents will be mailed to your postal address via USPS.• We may continue to send paper copies of certain documents, such as annual statements, if required by federal or state law. E-Delivery is not currently available for all E-Delivery Documents. When an E-Delivery Document becomes available for electronic delivery, we will initiate the E-Delivery process without any further action required by you.• Although there is no charge for E-Delivery, you may incur costs associated with electronic access to the E-Delivery Documents, such as usage charges from Internet access providers and telephone companies. We are not responsible for such charges.• With regard to your insurance policies, you may still request a paper copy of an E-Delivery Document at no charge by phone(1-855-287-9334) or by email (email@example.com).• Your consent to enrollment in E-Delivery will remain in effect for each selected policy until termination or cancellation of the policy. If termination or cancellation of the policy occurs, all notices and documents applicable to your selected insurance policies will be mailed to your postal address via USPS. You may revoke your consent to E-Delivery at any time by phone (1-855-287-9334) or by email (firstname.lastname@example.org). Please allow a reasonable time to process your un-enrollment in E-Delivery.• We reserve the right to modify these Terms and Conditions at any time. Continued participation in this E-Delivery option will constitute your acceptance of any revisions to the Terms and Conditions.• We are not required to deliver information electronically and may discontinue electronic delivery in whole or in part at any time.CONSENT FOR ELECTRONIC SIGNATUREI agree to the usage of electronic signature and electronic records for current and future transactions pertaining to my authorization conducted through this website, effective on the date I click the “Verify, Sign & Submit” button. I understand that I have the option to print and retain paper copies of any electronic records generated and to obtain paper copies of any electronic records generated during website transactions concerning my coverage(s) by phone (1-855-287-9334) or by email (email@example.com). I understand that to obtain paper copies of electronic records kept by Farmers concerning my coverage(s), or to withdraw my consent to usage of electronic records, I must contact Farmers. I understand that in the event of changes to my personal contact information or any error is detected, I must immediately notify Farmers. I understand that to access and conduct transactions relating to my coverage, I must have access to a personal computer which is capable of supporting Internet access, and a compatible browser application.ELECTRONIC FUND TRANSFER (EFT) AUTHORIZATIONI authorize Farmers New World Life Insurance Company (the Company) to initiate electronic funds transfer (EFT) withdrawals, by debiting my account indicated above. I authorize my financial institution to pay and charge such amounts to my account. I understand that if, at any time, I change financial institutions and/or accounts, a new form will need to be submitted. I agree that the Company’s rights in regard to each such withdrawal shall be the same as if it were a check written to the Company and signed personally by me. This authority is to remain in effect until the Company has received appropriate notice of its termination, in such time and manner as to afford the Company a reasonable opportunity to act upon it. I understand and agree the Company shall be fully protected in honoring any such withdrawal. I understand and agree that in the event any such withdrawal returned by my financial institution, whether with or without cause and whether intentionally or inadvertently, the Company shall be under no liability whatsoever even though such dishonor results in the forfeiture of insurance. I understand and agree the Company,at its discretion, may make or discontinue withdrawals from my account while this authorization is in effect. In the event of a dishonored draft for “Non-Sufficient Funds,” a replacement draft may be submitted to the account. In addition, I understand it’s my responsibility to assure payments are being withdrawn.
BY CLICKING THE “Verify, Sign & Submit” BUTTON, YOU AGREE THAT YOU HAVE READ AND ACKNOWLEDGE AND AGREE TO BE LEGALLY BOUND BY THE TERMS AND CONDITIONS OF THE: (1) CONSENT FOR ELECTRONIC DELIVERY; (2) CONSENT FOR ELECTRONIC SIGNATURE; AND (3) ELECTRONIC FUNDS AUTHORIZATION, AS IF YOU HAD SIGNED THIS AGREEMENT WITH A HAND WRITTEN SIGNATURE. YOU MAY PRINT OR RETAIN A COPY OF THIS AGREEMENT FOR YOUR RECORDS
ADB AUTH-2 11/15
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Accidental Death Application
Agree & Sign