Sample Mortgage Application Packet - TAG U Senior

Americo Financial Life 

and Annuity Insurance Company 

Home Office: Dallas, Texas • Administrative Office: P.O. Box 410288, Kansas City, MO 64141-0288 

Additional forms 

may be required 

depending on the 

amount of 

coverage, age, 

and state where 

the policy was 

sold. Refer to the 

Americo Forms 

Matrix on Agent 

Café. 

This is the 

premium 

quoted to the 

Proposed 

Insured. 

This is to annotate 

any amount 

of money submitted 

with the 

application. 

If you choose the 

Disability Income 

Rider or Critical 

Illness Accelerated 

Benefit Rider, be 

sure to include the 

necessary 

supplemental 

application(s). 

Sample Mortgage Application Packet 

If Social Security 

Number is not 

available, include 

IRS W-9 form with 

application. 

Annual or Monthly 

Bank Draft are the 

only modes 

available. 

04-130-1(12/06) © Americo 1 of 7 For Agent Use Only. Not For Public Use. 

State Variations Apply




Answer all questions regarding 

replacement. Any applicable 

replacement form(s) 

must be signed and dated on 

or before the date of the 

application and must be submitted 

with the application. 

In some states, a replacement 

form is required even if 

there is no replacement. 

Consult Agent Café for 

complete details. 

Not necessary 

to complete Mortgage 

Information 

section. 

Not necessary unless 

Owner or Payor differs 

from Proposed Insured. 






Always list 

medications 

separately in 

section 19 

below. 

In every case 

(even if only 

“no” answers 

above), always 

complete with 

name, address, 

etc. of physician 

and provide any 

medical history 

even if it seems 

minor or 

insignificant. 

Describe any 

“yes” answers in 

section 19 below. 

Include name, 

address, and 

telephone number 

of attending 

physician and/or 

medical 

facility. 






Additional 

forms may be 

required 

depending on 

the state where 

the policy was 

sold. Refer to 

the Americo 

Forms Matrix 

on Agent Café. 

Please note the 

witnessing agent 

signature is 

required on this 

application. 






Answer all questions 

regarding 

replacement. Any 

applicable 

replacement 

form(s) must be 

signed and dated 

on or before the 

date of the application 

and must 

be submitted with 

the application. 

In some states, a 

replacement form 

is required even if 

there is no 

replacement. 

Consult Agent 

Café for complete 

details. 

The policyowner 

or proposed 

insured(s) must 

have a mortgage 

at time of issue. 

Note the Agent 

Comments/ 

Remarks section. 

It is extremely important to fill in this section 

if sharing commissions with another agent. 

Provide agent number, name and 

percentage for accurate commission payout. 

Very important to 

clearly print agent 

number here for 

proper production 

credit. 






Use this receipt when 

no premium payment 

is received at the 

time of application. 

It must be signed and 

dated and submitted 

to the Home Office 

with the application. 

Use this receipt when 

a premium payment is 

received at the time of 

application. Tear off 

and leave with client. 






Tear off this portion and leave with client. 

Please note that on the back side of this 

notification is the conditional receipt, which 

should be signed if funds are received at 

the time of application. 

Be sure to staple a 

voided check or 

deposit slip here.

Sample Mortgage Application Packet - TAG U Senior

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