MWG Agent Quoter — Enrollment Complete!

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Primary Dependents Medical Questions Additional Information Beneficiaries Agreements Summary Billing Confirmation
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Billing Details
EFT/ACH Payment Bank Draft · David S. Smith
Annual
Agreements
Applicant’s Statement

Medical Authorization

Billing Authorizations
Payment Authorization

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                "I understand the broker, agent or agency receiving this application does not have authority to modify or waive any portion of this application or any coverage, conditions or restrictions contained in the insurance policy applied for and all information requested in this application must be set forth in writing on the application. I further understand this application will become part of the insurance policy to be issued and the insurer will be utilizing the information contained in this application to determine whether or not to issue the insurance policy applied for.",
                "I understand the broker, agent or agency taking this application from me is an independent representative and is acting on my behalf and not the administrator nor the insurance company offering this insurance. Neither the administrator nor the company offering this insurance can be held liable for any circumstance if the broker, agent or agency taking this application fails now or in the future to transmit or communicate any documentation or funds from the administrator to me and/or any documentation or funds from me to the administrator.",
                "It is understood the insurance applied for shall not become effective until this application is approved and accepted by the insurer, full payment of the first term premium is made, and the policy issued is subject to all conditions and restrictions contained therein. I understand this policy is not available to permanent resident of the United States or others who reside in the United States."
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                "I personally solicited and completed this application. All medical and non-medical questions were asked of each proposed insured and their answers were provided directly by the proposed insured."
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