207 Texas St. Post office Box 1803 Shreveport, Louisiana 71166-18003 Telephone 221-0646
207 Texas St. Post office Box 1803 Shreveport, Louisiana 71166-18003 Telephone 221-0646 | |
| Computed for: | |
| Date of Birth - | |
| Itemization | Truth in Lending Information | |||
| Loan Amount | Annual Percentage Rate | % | ||
| Amount Financed | 0.00 | |||
| Finance Charge | 0.00 | |||
| Number of Monthly Payments | ||||
| Payment Amount | 0.00 | |||
| Total of Payments | 0.00 | |||
| Total | ||||
| Insurance Information | ||||
| Single A & H insurance | ||||
| Principal Amount to Insure | 0.00 | Monthly A & H Benefits | ||
| Credit Life Insurance | 0.00 | Total Insurance Coverage | 0.00 | |
| Dismemberment | 0.00 | |||
| A & H Insurance | 0.00 | Daily insurance cost | 0.00 | |
| Total Insurance | 0.00 | Insurance per payment | 0.00 | |
| Amount to be financed | 0.00 | |||
HEALTH QUESTIONNAIRETo: Life Insurance Company of Louisiana | |
| DEBTOR | CO-DEBTOR (if applicable) |
| Full Name | Full Name ____________________________ |
| Sex _________ Date of Birth | Sex _________ Date of Birth _____________ |
| Place of Birth
___________________________ City County State |
Place of Birth
__________________________ City County State |
| Occupation ____________________________ | Occupation ____________________________ |
| Employer ______________________________ | Employer ______________________________ |
| Height / Weight __________________________ | Height / Weight _________________________ |
| Debtor | Co-Debtor |
| _________________________________________ | __________________________________________ |
| _________________________________________ | __________________________________________ |
| _________________________________________ | __________________________________________ |
AUTHORIZATION
TO ANY PHYSICIAN, HOSPITAL, CLINIC, INSURANCE COMPANY OR OTHER ORGANIZATION, INSTITUTION OR PERSON:| A photographic copy of this authorization shall be as valid as the original. | Date _____________________________________ |
____________________________________________________________________ |
________________________________________________________________ |
| Signature of Proposed Debtor | Signature of Proposed Co-Debtor |