Applicant Information

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VidaPass Life Insurance

Application

You will be charged a one-time $30 application fee.
This product is available to non-US citizens, and if you are NOT residing in your country of origin.
All fields marked with asterisk (*) are required.


Country of Origin Address


Benefits Amount Selection


Annual Premium

Please reference the chart below for applicable premium amount

Age $10,000 Benefit Amount $15,000 Benefit Amount $25,000 Benefit Amount
18-40 $100 $150 $250
41-65 $200 $300 $500
* All premiums are reflected in USD and in annual amounts. Premium must be paid as a single payment.

Premium Payment Option

Benefit Proceeds Payment Selection


Beneficiary Designation Information


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*Beneficiaries must be 18 years of age or older. *Where no percentages are specified, benefit proceeds will be divided equally among the beneficiaries if more than one beneficiary is designated. If no beneficiary has been designated, proceeds of this Policy plus any funeral expenses will be distributed by legal precedence.


Agreement and Authorization

Applicant confirms that the answers and statements contained herein are true, complete, and accurate. Applicant understands and agrees to the following

  1. This completed application, and any supplements or amendments will be a part of any policy, if issued.
  2. The broker may only submit the application and initial payment on my behalf, and may not promise me coverage, modify WellAway Limited’s underwriting policy or terms of coverage, or change or waive any right or requirement.
  3. If WellAway Limited rejects this application, under no circumstances will any benefits be payable.
  4. I declare that I am not, nor will be engaged in business with any country, person or activity listed by the U.S. Treasury’s Office of Foreign Assets Control (OFAC) http://www.ustreas.gov/offices/enforcement/ofac/ or any other similar office or organization.
  5. I understand and agree that misrepresentations, intentionally fraudulent or incorrect statements, omissions, concealment of facts, or incomplete information on this application may result in voidance of coverage, denial of benefits, claim denial and/or termination of coverage.
  6. I authorize WellAway to share this information with any of its representatives or partners involved in providing the services and coverage agreed upon.

* It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company.


Broker/Agent Statement

I attest that any assertions made to the client regarding WellAway products are in accordance with the Policy Terms and Conditions,Certificate of Coverage and other marketing materials provided by WellAway Limited.

The contents of this material are the exclusive intellectual property of WellAway Limited. No reproduction, changes or copying is possible without the consent of WellAway Limited. The WellAway brand and WellAway logos are the registered marks of WellAway Limited and WellAway SA, Hamilton, Bermuda.