Critical Illness Insurance Request Form

  • Applicant's Information

  • Beneficiaries

  • General Section

• There must be at least 180 days between the dates of diagnosis of multiple conditions or procedures from multiple categories.
• Benefit amount reduces 50 percent on the policy anniversary date in the year the insured turns 65 or five years from the policy issue date, whichever is later.
• Invasive and non-invasive cancers have a reduced benefit for the first 90 days of the policy. If cancer is diagnosed during the policy’s first 90 days, the policy pays 10 percent of the benefit for invasive cancer or 2.5 percent of the benefit for noninvasive (in situ) cancer. If a cancer is diagnosed after the policy’s first 90 days, the invasive cancer
benefit is 100 percent and non-invasive cancer is 25 percent.

This policy contains other reductions of benefits, limitations and exclusions. For costs and complete details of the coverage, please contact your agent, Assurity Life Insurance Company or ask to review the policy for more information.