Application GuideNGL AssetGuard

The Standard NGL AssetGuardApplication Form

2735FE 12/08(Applications will vary by state; before writing new business, please verify the current version approved for your use on MyNGLIC)

Application Example: Insured/Annuitant Information

Be sure to indicate Male or Female

Any missing information could result in issuance delay

Complete all information on this line, if applicable

Complete all information on this line

Complete all information on this line

Where should the policy be mailed?

Payment Methods & Modes

The Health Question*: Determines Underwriting Class

Health question must be answered “NO” for Standard Issue.If answered “YES” or not answered, Guaranteed Issue will be used.

* May vary by state.

Payment Plan + Mode

* “Increased Face Amount” (based on funeral price) or “Inflation Protected” amount. Use Premium Calculators on MyNGLIC to best calculate Face Amount.

15th

Bank Of America

1234567870-1238901

5,000.00

X

Remember to check box C to indicate growth rate!

Beneficiary Information

Write the name and address of where proceeds should be directed. If it is Insured’s Estate, please write “Estate of Insured”.

If assigning to one of NGL’s Trusts, please be sure to specify which:NGL Funeral Expense Trust or NGL Estate Planning Trust.

NGL Funeral Expense Trust

The Signature Section(s)

If your state application includes any replacement questions,all of the questions must be completed.

Only use 2nd line in Agent Statement if splitting commissions

City/Town where sale is MADE State of Sale

Insured Signature Date Owner Signature Date

Agent Signature Agent PRINTS Name NGL Agent # Here Agent License # %

Remember to complete both Applicant’s AND Agent’s Sections

Acknowledgment of Payment

Agent Signature Date

John Smith 5,000

Trust Assignments

NGL Funeral Expense Trust

NGL Estate Planning Trust

NGL Funeral Expense Trust Assignment Form (#2591-FET*)

• Use this trust if the client is concerned with Medicaid Qualification

• Excess proceeds paid to the Estate of the Insured (or the state, if your state requires it)

• Policyholder must sign. If Power of Attorney (POA), include POA paperwork.

John E. SmithMary K. Smith

(Optional)

Owner Signature Date

* May be state-specific. Please check MyNGLIC.

NGL Funeral Expense Trust Assignment Form

For NGL Use Only.

Use ONLY if your client needs to immediately apply for Medicaid and transfer the ownership rights immediately.

NGL Estate Planning Trust Assignment Form (#2591-EPT)

• Excess proceeds paid to the beneficiary named on the form

• Policyholder must sign. If Power of Attorney (POA), include POA paperwork.

• May be used in combination with the Funeral Expense Trust. Total value of the combined policies may not exceed the Estate Planning Trust maximum (may vary by state).

John E. SmithMary K. Smith

John E. Smith, Jr.

Owner Signature Date

Reminders and FAQs

Helpful Reminders

• Indicate where/to whom the policy should be sent on the top of the application .

• If EFT is being drawn from a:

–Checking Account: Please include a voided check.

–Savings Account: Please have the applicant contact the bank to get the correct bank information and verify that EFT withdrawals are allowed.

To ensure that your application can be processed quickly, please remember:

Common Application Errors• Incomplete/Missing Information:

– Agent statement and replacement questions are incomplete– Signature Date is missing– Missing or incomplete state requirements such as disclosures or

trust assignment forms• May be caused by using old forms, which may not have all the

current state requirements included

• Premium Discrepancies:– Using standard rates on guarantee issue cases

• Payment Type Issues:– Agent’s personal checks are not accepted– Money Orders must be purchased by the applicant (not the

agent) and MUST be signed.

• For any contract or policy changes, please contact the Agent Support Team

Submitting Applications and Claims

Submitting Applications via Fax• Complete Application Cover

Page (#2802)• Fax with Application to:

866.228.9927• Please ensure this form is

the FIRST PAGE of your fax.

• Do not fax and mail your application materials; send via fax or via mail, not both. Please fax the application just ONCE.

• We are only able to accept faxed payment for initial premium from one account. Initial premium payments from multiple accounts must be mailed to NGL with checks from each account.

• Business should not be sent to NGL until it is ready to be issued.

Claims Process• Claims may be submitted via fax and are generally

processed in two business days or less.

• A copy of the death certificate is required:

• If death occurs within the first two years of issue on a standard issue policy, a death certificate is required

• In Kentucky, Louisiana, Ohio and Wisconsin.

Covered Funeral and Burial Items

• Professional services• Embalming and other

treatment of remains

• Cremation• Caskets• Vaults• Funeral home

facilities and services

• Stationery• Flowers• Transportation of the

body• Opening and closing

of the grave• Cemetery charges

Copies of bills for the funeral (or other related services) should be submitted with the claim form. These may include:

Submitting Claims via Fax

• Complete the appropriate Claim Form:– NGL Funeral Expense Trust

Claim Form (#FE-CF)*

– NGL Estate Planning Trust Claim Form (#EP-CF)*

– Beneficiary Claim Form (#2803PNCF)*

– Multiple Payees Claim Form (#FE-MP-CF)*

• Fax to: 866.228.9450

* Some states use state-specific forms. Check MyNGLIC to ensure correct form usage.

© 2010 National Guardian Life Insurance Company, Madison, WI. NGL, National Guardian and the tree of life logo are registered trademarks of National Guardian Life Insurance

Company. National Guardian Life Insurance Company is not affiliated with the Guardian Life Insurance Company of America, a/k/a The Guardian or Guardian Life.

For Agent Use Only. ABLAG-BSP

Call 800.356.5306 for assistance!

Questions?