Application for: Accident Policy

To: Gerber Life Insurance Company, White Plains, NY

Primary Insured

Your First Name *
Middle Initial
Last Name *
Address *
Phone *
City *
State *
Zip Code *
Date of Birth *
Sex * (Must be between 18 to 69) Email *

Payment Options and Monthly Rates

State	50k	100k	200k	300k	400k	500k
ACH Payments - NY, MA, MN	$3.67	$7.33	$14.67	$22.00	$29.33	$36.67
ACH Payments - All other states	$5.23	$10.45	$20.90	$31.35	$41.80	$52.25
Add 1-6 Children (Under 18) — $1.20 for $25k
CC/Debit - NY, MA, MN	$4.00	$8.00	$16.00	$24.00	$32.00	$40.00
CC/Debit - All other states	$5.70	$11.40	$22.80	$34.20	$45.60	$57.00
Add 1-6 Children (Under 18) — $1.31 for $25k per Month

Amount of Coverage for You

Amount of Coverage for Spouse

Beneficiaries

Beneficiary Name *
Relationship *
Beneficiary Name
Relationship
Contingent Beneficiary Name
Relationship
Contingent Beneficiary Name
Relationship

Other Insurance

Do you plan to replace, cancel or change any other accident insurance when you get ours?* If yes, please provide the name of the other company

Spouse/Domestic Partner

Name
DOB
Gender

Children (1-6, under 18 - $25,000 Coverage Each Child)

Name
DOB
Gender
Name
DOB
Gender
Name
DOB
Gender
Name
DOB
Gender
Name
DOB
Gender
Name
DOB
Gender

NY Residents Only

Do you have Federally approved Health insurance?
GOVERNMENT ID # *
ID Type
Driver’s LicensePassportGreen Card

Authorizations

STEP 1: You will acknowledge that you are the Insured, Owner and/or Payor of the proposed insurance contract.
STEP 2: You will agree to show proof of identification.
STEP 3: You will agree to read the Gerber Life Insurance Company's Portal Terms of Use.
STEP 4: You will agree to review all documents and disclosures.

An agent from Octans Insurance will be in touch with you within 48 hours! Thank you so much for filling out this form — we're super excited to help you with this new coverage opportunity!

Application for: Accident Policy