ManhattanLife Assurance Company of America
10777 Northwest Freeway, Houston, TX 77092
Dental, Vision, and Hearing Insurance Application
WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto maybe committing a fraudulent insurance act, which is a crime.
The insurance shall not take effect unless and until the application has been accepted and approved by ManhattanLife Assurance Company of America (Company), the full first premium has been paid, and the policy has been delivered to the applicant; and, (b) oral statements between the agent and myself are not binding on the Company unless accepted by the Company in writing.
This application is for individuals and families (up to 5 persons, applicant and 4 dependents). If you will need to add more than 4 dependents, please contact firstname.lastname@example.org for a different form to fit your needs.