Youth Life Application

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Youth Life Insurance - the Youth Life Plan

Children's Life Insurance for the Budget-Minded Parent or Grandparent

New Policy Application

Available to Residents of Arizona and Utah Only


Required fields marked with an *

Step 1

Please choose your benefits:

Amount of Insurance Protection Annual Premium through age 24 Premium from age 25 to 100 Max APD Balance*
$25 $90 $7,000
$50 $180 $14,000
*Advance Premium Deposit accounts (APDs) are an optional savings account in which Owners may deposit and earn interest on up to $7,000 for every $10,000 of Youth Life insurance in force. The current minimum guaranteed interest rate for APDs is 4.0% per annum. There are no annual fees and no restrictions on when the funds can be withdrawn. APDs are not bank deposits and are not FDIC insured. They are a feature of premium paying life insurance policies from American Savings Life Insurance Company.

Step 2

Proposed Insured:

(Applicants must be between 6 months and 24 1/2 years old)

Child 1
First Name(s)*  
Last Name*  
Height*
ft. in.    
Weight*    
Gender*
Born*
 

Has the Proposed Insured received any medical advice, examination or treatment during the past three years?

 
If "Yes", please explain:  

Does the Proposed Insured have any existing impairments, diseases, health or medical conditions?

 
If "Yes", please explain:  

Will you replace or change any existing life insurance or annuities when this policy is issued?

 
If "Yes", please list below the name of the Company and the policy number so we can notify them:  

Child 2
First Name(s)*  
Last Name*  
Height*
ft. in.    
Weight*    
Gender*
Born*
 

Has the Proposed Insured received any medical advice, examination or treatment during the past three years?

 
If "Yes", please explain:  

Does the Proposed Insured have any existing impairments, diseases, health or medical conditions?

 
If "Yes", please explain:  

Will you replace or change any existing life insurance or annuities when this policy is issued?

 
If "Yes", please list below the name of the Company and the policy number so we can notify them:  

Child 3
First Name(s)*  
Last Name*  
Height*
ft. in.    
Weight*    
Gender*
Born*
 

Has the Proposed Insured received any medical advice, examination or treatment during the past three years?

 
If "Yes", please explain:  

Does the Proposed Insured have any existing impairments, diseases, health or medical conditions?

 
If "Yes", please explain:  

Will you replace or change any existing life insurance or annuities when this policy is issued?

 
If "Yes", please list below the name of the Company and the policy number so we can notify them:  

Child 4
First Name(s)*  
Last Name*  
Height*
ft. in.    
Weight*    
Gender*
Born*
 

Has the Proposed Insured received any medical advice, examination or treatment during the past three years?

 
If "Yes", please explain:  

Does the Proposed Insured have any existing impairments, diseases, health or medical conditions?

 
If "Yes", please explain:  

Will you replace or change any existing life insurance or annuities when this policy is issued?

 
If "Yes", please list below the name of the Company and the policy number so we can notify them:  

Child 5
First Name(s)*  
Last Name*  
Height*
ft. in.    
Weight*    
Gender*
Born*
 

Has the Proposed Insured received any medical advice, examination or treatment during the past three years?

 
If "Yes", please explain:  

Does the Proposed Insured have any existing impairments, diseases, health or medical conditions?

 
If "Yes", please explain:  

Will you replace or change any existing life insurance or annuities when this policy is issued?

 
If "Yes", please list below the name of the Company and the policy number so we can notify them:  


Step 3

Applicant and Policy Owner Information:

First Name(s)*  
Last Name*  
Address*  
City*  
State*  
Zip*    
Primary Phone*  
Second Phone
Email*    
Relationship to Proposed Insured*  
Relationship if "Other"  

Beneficiary Information:

First Name(s)*  
Last Name(s)*  
Relationship to Proposed Insured*  
Relationship if "Other"  

Step 4

Comments & Questions:


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BY CLICKING "SUBMIT" I AGREE THAT: (a) the information above is true and complete to the best of my knowledge and belief; (b) this Application shall be the basis for and a part of the policy; (c) no insurance shall take effect until a policy is issued and the premium is timely received by the Company while the health of the Proposed Insured is as described in the application.