HIPAA Compliant Authorization for Life Insurance

I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, prescription benefit manager, or other health care provider that has provided payment, treatment or services to me or on my behalf within the past 10 years (collectively, "My Providers") to disclose my entire medical record, prescription drug information, and any other protected health information concerning me to My Term Life Guy Life Insurance Company (“Company”), The Company's agents, employees, and Life Insurance Carriers that they are submitting my applications to. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs and tobacco, but excludes psychotherapy notes.

By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this Authorization and I instruct My Providers to release and disclose my entire medical record without restriction.

The protected health information and driving records are to be disclosed under this Authorization so that The Company may:

• submit and underwrite my application for coverage, make eligibility, risk rating, policy issuance and enrollment determinations
• obtain reinsurance
• administer claims and determine or fulfill responsibility for coverage and provision of benefits
• administer coverage
• conduct other legally permissible activities that relate to any coverage I have or have applied for with The Company.

This Authorization shall remain in force for 30 months following the date of my signature below, and a copy of this Authorization is as valid as the original. I understand that I have the right to revoke this Authorization in writing, at any time, by sending a written request for revocation to 980 N Federal Hwy Suite #110 Boca Raton, FL 33432. I understand that a revocation is not effective to the extent that any of My Providers has relied on this Authorization or to the extent that The Company has a legal right to contest a claim under an insurance policy or to contest the policy itself. I understand that any information that is disclosed pursuant to this Authorization may be re-disclosed and no longer covered by federal rules governing privacy and confidentiality of health information.

I understand that My Providers may not refuse to provide treatment or payment for health care services if I refuse to sign this Authorization. I further understand that if I refuse to sign this Authorization to release my complete medical record, The Company may not be able to process my application, or if coverage has been issued, may not be able to make any benefit payments. I acknowledge that I have received a copy of this Authorization.

Electronic Record and Signature Disclosure and Consent

Electronic Record and Signature Disclosure and Consent

From time to time, My Term Life Guy Life Insurance Company or its affiliates (collectively, “we”, “us”, or “Company”) may send you certain notices, agreements, acknowledgments, disclosures, or other documents including those which may be required by law (collectively, “Documents”). Law may require us to provide those documents “in writing.” However, we may provide those documents electronically so long as you agree to these terms and conditions for providing to you such Documents electronically through the Company website, Company customer portal, or other electronic means.

To continue with this electronic life insurance transaction process, including accepting electronic delivery of any notices and required disclosures, you must agree to this Electronic Record and Signature Disclosure and Consent (“Electronic Consent”), please confirm your agreement by proceeding with your estimate, including by providing us your email address and telephone number. By clicking the “See Your Results” button and/or retrieving an estimated premium you agree to this Electronic Consent.

Telephone Consumer Protection Act and State-Law Equivalents

We want to talk to you!

You consent to be contacted via telephone, email, and texts by My Term Life Guy Life Insurance Company, its employees, agents, affiliates, and others acting on its behalf (collectively, “My Term Life Guy”) relating to insurance products, surveys, and research. Standard rates may apply and you can opt out at any time. You also agree that we may include your personal information in a communication. You understand that email and text are not secure and that a third party may see our correspondence. By communicating with us via email or text, you are consenting to that type of contact. We may use an automatic dialing system or pre-recorded or artificial voice messages to contact you. You agree that we may send you communication at any landline, cell phone, or email address that you provide or that is publicly available and associated with you and that you agree we may contact you now or in the future. You may opt out of receiving communications at any time by contacting My Term Life Guy. Consent is not a condition of purchase. You can simply call us at 1-866-NOEXAM1 if you would like to discuss your insurance options without giving this consent. You agree to receive text messages from Amplify Life Insurance and associated partners. Additionally user can opt out by texting back STOP to discontinue receiving text messages.

Voice Signature Authorization

You will receive a copy of your application package including important notices and authorization. In connection with your estimate and any application submitted by My Term Life Guy Life Insurance Company (“Company”) at your request, it is understood and agreed that you have read or have been read the application and all statements and answers made or contained in this application and any supplements thereto, copies of which shall be attached to and made a part of any policy to be issued, are true and complete to the best of your knowledge and belief and made to induce Company or its insurance carrier partners to issue an insurance policy.

The statements and answers in the application are the basis for any policy issued through the Company and no information about you will be considered to have been given to the Company or its carrier partners unless it is stated in the application.

No agent or other person associated with the Company has power to: accept insurance risk; make or modify contracts; make, void, waive or change any conditions or provisions of the application, policy, or delivery receipt, as applicable; waive any of Company’s or its carriers’ rights or requirements; waive any information the Company or its carriers request; discharge any contract of insurance; or bind the Company or its carriers by making promises respecting benefits upon any policy to be issued.

You agree that insurance coverage will not begin unless all persons proposed for insurance are living and insurable as set forth in the application at the time a policy is delivered to and accepted by you and the first modal premium is paid.

Fraud Statement

I understand that any person who knowingly and with intent to defraud or damage files an insurance application or claim containing false, incomplete, or misleading information may be in violation of state law.

Terms and Conditions

• General
  My Term Life Guy Life Insurance Company (“My Term Life Guy,” “we,” “us,” “our”) operates the website https://mytermlifeguy.com/ (the “Site”). By using the Site, you agree to the Terms and Conditions outlined here. If you disagree, you may close the Site. Questions? Contact us at sales@mytermlifeguy.com.
• Privacy
  Our Privacy Policy explains what information we collect, how we use it, and how we may share it. By using the Site, you agree to the collection and use of your information as described in the Privacy Policy.
• Representations
  My Term Life Guy provides insurance quotes and information through the Site. Quotes are based on the information you provide, and incorrect info may affect your quotes. You assert that you are at least 13 years old and have the authority to enter into this Agreement.
• Intellectual Property
  All content on the Site belongs to My Term Life Guy and is protected by copyright and trademark law. You may use the Site for personal, non-commercial purposes only.
• Restrictions
  You agree not to copy, modify, reverse-engineer, or misuse the Site. Unauthorized use of the Site may lead to termination of your access.
• Submissions
  By submitting any non-personal information to the Site, you grant My Term Life Guy a license to use it for any purpose. Do not submit unlawful, offensive, or inappropriate content.
• Third Parties
  My Term Life Guy provides information about third-party insurance products but is not responsible for these third-party offerings. You are responsible for investigating and validating third-party services.
• Communications
  By providing your email or phone number, you consent to being contacted regarding your insurance needs. To stop receiving emails, you can unsubscribe at any time. Message and data rates may apply.
• No Warranties
  The Site is provided “as-is” without any warranties. Use it at your own risk. We are not responsible for any damages that may result from using the Site.
• Limitation of Liability
  My Term Life Guy is not liable for any direct or indirect damages resulting from the use of the Site. This limitation may vary by state.
• Changes to Agreement
  We may update this Agreement at any time. By continuing to use the Site, you agree to the updated terms.
• Governing Law
  This Agreement is governed by the laws of California, and any disputes will be resolved in San Mateo County, California.
• Employment
  My Term Life Guy is an equal opportunity employer and encourages all qualified applicants to apply.
• Miscellaneous
  If any part of this Agreement is invalid, the rest remains in effect. The headings are for convenience only and have no legal effect.