![]() 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 | ||||
Insurance Term | 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 | ||||
YES | NO | YES | NO | ||
1. Are you now in good health and free from the effects of any illness or injury? | |||||
2. Have you, during the last 5 years, had or been advised of or treatment for any
of the following: (a) High Blood Pressure, Heart Disease, Stroke, Blood Disorder, Cancer, Tumor, Diabetes, Obesity or Mental Disorder? (b) Diseases or disorder of the Lung, Liver, Brain, Kidney, Stomach or intestines. (c) Alcoholism, Drug Abuse, AIDS or ARC (AIDS Related Complex) |
|||||
3. Have you ever had an insurance application rated, declined or otherwise not issued as requested? | |||||
TO BE COMPLETED IN ADDITION IF DISABILITY INSURANCE IS APPLIED FOR. (ONLY DEBTOR ELIGIBLE FOR DISABILITY INSURANCE) | |||||
4. Are you now working 30 hours a week at your regular occupation? | |||||
5. During the past 5 years, have you consulted a Doctor or Practitioner for Back Problems, injury or Accident, Physical, Mental or Nervous Problems, or any problem which has caused you to be other than in good health? |
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 |