We are required to provide the following Disclosure Statement to you. This notice contains information about the insurance that you are applying for. You will be required to read this notice, and acknowledge that you have read the notice before the application process can continue.
Please be advised a printer is required if an immediate copy of this application is desired. Also, please note, we will provide a paper copy of the electronic application bearing your electronic signature, at any time you request it and without charge.
| Headquarters: | 6200 S. Gilmore Road, Fairfield, OH 45014-5141 |
| Mailing address: | P.O. Box 145496, Cincinnati, OH 45250-5496 |
| Mailing Address: | P.O. BOX 145496, CINCINNATI, OHIO 45250-5496 |
| Home Office: | FAIRFIELD, OHIO 45014-5141 |
www.cinfin.com * (513) 870-2000
Customer Electronic Consent and Disclosure
IMPORTANT NOTICE — PLEASE READ CAREFULLY AND KEEP FOR FUTURE REFERENCE
To apply for life insurance coverage via an electronic application with an electronic signature, you must consent to the use of your electronic signature and the electronic transmission of the application to The Cincinnati Life Insurance Company (Cincinnati Life). By selecting I Consent below, you agree to provide Cincinnati Life and your agent with your consent to submit your application electronically with your electronic signature. If you do not wish to submit your application electronically, select I Do Not Consent and your agent will need to complete a paper application, including your written signature.
By selecting I Consent, you agree to print or save this Consent and Disclosure and the electronic application, and keep printed or electronic copies for your records. You may obtain a paper copy of the electronic application forms bearing your electronic signature, at any time and without charge, by contacting Cincinnati Life at the address provided below.
To access and retain the electronic application sent or made available to you electronically by Cincinnati Life, you must have access to a computer with an Internet connection. You must be able to send and receive e-mails, and be able to save the electronic application to a storage device for later reference or have the computer connected to a printer so you can print out such document.
If you choose to withdraw your consent after selecting I Consent, please notify your agent or Cincinnati Life at 513-870-2227 or The Cincinnati Life Insurance Company, Life Policy Issue Dept, P.O. Box 145496, Cincinnati, Ohio 45250-5496. If you withdraw consent, the application will be considered withdrawn and no further processing will occur. To have your application considered further, please contact your agent to complete and submit a new application.
PLEASE PRINT OR SAVE A COPY OF THIS CONSENT AND DISCLOSURE NOW FOR FUTURE REFERENCE.
I have CAREFULLY read this Consent and Disclosure and accept it voluntarily and with full knowledge and understanding of its terms and conditions.
I understand I am consenting to the use of my electronic signature by electronic submission, which is valid for this application and associated forms dated only.
I have successfully printed or saved a copy of this Consent and Disclosure.
Form CLI-6316-PA
Form CLI-6316