Confirmation - Accidents Happen.

Automatic Monthly Deduction Checking Account Authorization

I request and authorize Farmers New World Life Insurance Company to make monthly withdrawals against the checking account I previously authorized under Life Insurance Policy . This authority is to remain in effect until the Company has received appropriate notice of its termination, in such time and manner as to afford the Company a reasonable opportunity to act upon it. I understand and agree that in the event such withdrawal is returned by my financial institution, the Company shall be under no liability for any returned check and that the returned check results in the lapse of coverage.

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Product
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EP Token
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Benefits*
- Additional Coverages
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Additional Benefits*
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Coverage*
- Member Only
- Family
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We are sorry, but you are too young for this product. Please select from options below.
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Other Options
- Return To website
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you are too old to qualify for this product. Please select from options below.
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Other Options
- Return To website
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GWKey
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Eligible Policy Owner*
First Last
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Social Security Number
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Street Address*
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Address Line 2
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City*
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State*
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Zip Code*
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Birth Date
Month
Day
Year
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Birth Date
Month
Day
Year
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Gender*
- Male
- Female
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Phone
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Email*
Enter Email Confirm Email
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Will any accident and health insurance presently in force be replaced, lapsed or otherwise terminated if the insurance applied for is issued?*
- Yes
- No
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Beneficiary*
- Estate of the Insured
- Name your Beneficiary
NOTE: If no beneficiary is named, the benefit will be paid to the Insured's estate.
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Beneficiary 1
First Last
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Relationship*
By submitting this information, I provide my signature expressly consenting to receive communications via automatic telephone dialing system or by artificial/pre-recorded message, or by text message from multiple insurance companies or their agents, at the telephone number above, including my wireless number if provided. I understand that my consent is not required as a condition of purchasing any goods or services. Your carrier's message and data rates may apply. I understand that I can revoke this consent at any time.
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Age
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Quarterly
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Semi Annual
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Annual
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Address
Street Address Address Line 2 City State ZIP Code
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Birth Date
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Social Security Number
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Percentage*
Please enter a number from 0 to 100.
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Beneficiary 2
First Last
Please leave blank if there are no additional beneficiaries.
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Beneficiary 2 Address
Street Address Address Line 2 City State ZIP Code
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Relationship*
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Birth Date
MM slash DD slash YYYY
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Social Security Number
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Percentage*
Please enter a number from 0 to 100.
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Beneficiary 3
First Last
Please leave blank if there are no additional beneficiaries.
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Beneficiary 3 Address
Street Address Address Line 2 City State ZIP Code
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Relationship*
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Birth Date
MM slash DD slash YYYY
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Social Security Number
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Percentage*
Please enter a number from 0 to 100.
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Beneficiary 4
First Last
Please leave blank if there are no additional beneficiaries.
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Beneficiary 4 Address
Street Address Address Line 2 City State ZIP Code
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Relationship*
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Birth Date
MM slash DD slash YYYY
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Social Security Number
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Percentage*
Please enter a number from 0 to 100.
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Beneficiary 5
First Last
Please leave blank if there are no additional beneficiaries.
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Beneficiary 5 Address
Street Address Address Line 2 City State ZIP Code
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Relationship*
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Birth Date
MM slash DD slash YYYY
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Social Security Number
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Percentage*
Please enter a number from 0 to 100.
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Beneficiary 6
First Last
Please leave blank if there are no additional beneficiaries.
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Beneficiary 6 Address
Street Address Address Line 2 City State ZIP Code
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Relationship*
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Birth Date
MM slash DD slash YYYY
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Social Security Number
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Percentage*
Please enter a number from 0 to 100.
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Total
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Percentage*
The percentages entered for beneficiary does not total 100%. Please enter percentages that total 100%.
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Benefit Amount
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Monthly Premium Amount
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Fraud Warnings*
Before signing this enrollment form, please read the warning for the state where you reside and for the state where the contract under which you are applying for coverage was issued.

Alabama, Arkansas, District of Columbia, Louisiana, Massachusetts, Minnesota, New Mexico, Ohio, Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Kansas and Oregon: Any person who knowingly presents a materially false statement of claim may be guilty of a criminal offense and may be subject to penalties under state law.

Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Maine, Tennessee and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

New York: (only applies to Accident and Health Benefits): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Oklahoma: WARNING: Any person who knowingly, and with the intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Puerto Rico: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or files, assists or abets in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years.

Vermont: Any person who knowingly presents a false statement of claim for insurance may be guilty of a criminal offense and subject to penalties under state law.

Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated the state law.

Pennsylvania and all other states: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
I have reviewed the Fraud Warnings
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Farmers Privacy Notice
Famers New World Insurance Company

Our Privacy Notice

We know that you buy our products and services because you trust us. This notice explains how we protect your privacy and treat your personal information. It applies to current and former customers. “Personal information” as used here means anything we know about you personally.

1. Plan Sponsors and Group Insurance Contract Holders

This privacy notice is for individuals who apply for or obtain our products and services under an employee benefit plan, group insurance or annuity contract, or as an executive benefit. In this notice, “you” refers to these individuals.

2. Protecting Your Information

We take important steps to protect your personal information. We treat it as confidential. We tell our employees to take care in handling it. We limit access to those who need it to perform their jobs. Our outside service providers must also protect it, and use it only to meet our business needs. We also take steps to protect our systems from unauthorized access. We comply with all laws that apply to us.

3. Collecting Your Information

We typically collect your name, address, age, and other relevant information. We may also collect information about any business you have with us, our affiliates, or other companies. Our affiliates include life, car, and home insurers. They also include a legal plans company and a securities broker-dealer. In the future, we may also have affiliates in other businesses.

4. How We Get Your Information

We get your personal information mostly from you. We may also use outside sources to help ensure our records are correct and complete. These sources may include consumer reporting agencies, employers, other financial institutions, adult relatives, and others. These sources may give us reports or share what they know with others. We don’t control the accuracy of information outside sources give us. If you want to make any changes to information we receive from others about you, you must contact those sources.

The information may be kept by the consumer reporting agency and later given to others as permitted by law. The agency will give you a copy of the report it provides to us, if you ask the agency and can provide adequate identification. If you write to us and we have asked for a consumer report about you, we will tell you so and give you the name, address and phone number of the consumer reporting agency.

5. Using Your Information

We collect your personal information to help us decide if you’re eligible for our products or services. We may also need it to verify identities to help deter fraud, money laundering, or other crimes. How we use this information depends on what products and services you have or want from us. It also depends on what laws apply to those products and services. For example, we may also use your information to:

administer your products and services
process claims and other transactions
perform business research
confirm or correct your information
market new products to you
help us run our business
comply with applicable laws

6. Sharing Your Information With Others

We may share your personal information with others with your consent, by agreement, or as permitted or required by law. We may share your personal information without your consent if permitted or required by law. For example, we may share your information with businesses hired to carry out services for us. We may also share it with our affiliated or unaffiliated business partners through joint marketing agreements. In those situations, we share your information to jointly offer you products and services or have others offer you products and services we endorse or sponsor. Before sharing your information with any affiliate or joint marketing partner for their own marketing purposes, however, we will first notify you and give you an opportunity to opt out.

Other reasons we may share your information include:

doing what a court, law enforcement, or government agency requires us to do (for example, complying with search warrants or subpoenas)

telling another company what we know about you if we are selling or merging any part of our business

giving information to a governmental agency so it can decide if you are eligible for public benefits

giving your information to someone with a legal interest in your assets (for example, a creditor with a lien on your account)

giving your information to your health care provider

having a peer review organization evaluate your information, if you have health coverage with us

those listed in our “Using Your Information” section above

7. HIPAA

We will not share your health information with any other company – even one of our affiliates – for their own marketing purposes. The Health Insurance Portability and Accountability Act (“HIPAA”) protects your information if you request or purchase dental, vision, long-term care and/or medical insurance from us. HIPAA limits our ability to use and disclose the information that we obtain as a result of your request or purchase of insurance. Information about your rights under HIPAA will be provided to you with any dental, vision, long-term care or medical coverage issued to you.

8. Accessing and Correcting Your Information

You may ask us for a copy of the personal information we have about you. Generally, we will provide it as long as it is reasonably locatable and retrievable. You must make your request in writing listing the account or policy numbers with the information you want to access. For legal reasons, we may not show you privileged information relating to a claim or lawsuit, unless required by law.

If you tell us that what we know about you is incorrect, we will review it. If we agree, we will update our records. Otherwise, you may dispute our findings in writing, and we will include your statement whenever we give your disputed information to anyone outside.

9. Questions

We want you to understand how we protect your privacy. If you have any questions or want more information about this notice, please contact us. When you write, include your name, address, and policy or account number.

We may revise this privacy notice. If we make any material changes, we will notify you as required by law.
I agree to the Privacy Notice
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