APPLICATION TERMS AND CONDITIONS FOR NO MEDICAL EXAM & INSTANT LIFE INSURANCE COVERAGE ($5K,$10K, $15K)

In order to qualify for coverage, I understand and agree to the following:
 
I represent that I am an Illinois resident or otherwise agree that Illinois law applies to this
policy in the event that I am not a resident or cease to be an Illinois resident.
 
I represent that I am over the age of 17 but under the age of 66; am not a smoker; do not
have and have never been treated for diabetes, asthma, COVID-19, lung disease, COPD,
depression or any mental health problem, hepatitis, drug or alcohol abuse, heart disease or
heart attack, stroke, seizures, Alzheimer's disease, cancer, or liver or kidney disease; am
not currently hospitalized, in a nursing home or assisted living facility, or under hospice
care; am taking all medications as prescribed by a licensed physician; have not been
diagnosed with a terminal disease, illness, or condition by a licensed physician; and am not
obese (i.e. BMI under 30).


I represent that this application is not intended to replace any other coverage I may have.
I also agree to email proof of identify to admin@lifeassurancecoa.com in a form listed
below:


(U.S. Citizenship is not required, but you must email a driver’s license, foreign driver’s
license, passport, foreign passport, Visa, foreign birth certificate, state ID, or any other
acceptable form agreed to by Life Assurance Company of America, that matches your full
name)

Life Assurance Company of America
17W220 22nd Street - Suite 410
Oakbrook Terrace, IL 60181

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