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G-16(A) Credit Insurance, Debt Cancellation Coverage,
or Debt Suspension Coverage Model Form

OPTIONAL COSTS
Option to Purchase (Name of Product)
STOP. You do not have to buy (name of product) to [get][keep] this line of credit. Go to (Web site of the
Federal Reserve Board) to learn more about this product.
Do I need this
product?

[These payments will only temporarily suspend your payments due and will not reduce the
balance you owe. Your balance will actually increase during the suspension period as
interest continues to accumulate.] If you already have enough insurance or savings to
[pay off this line of credit][make payments on this line of credit] if you (covered event), you
may not need this product.
Other types of insurance can give you similar benefits and are often less expensive.

How much does it
cost?

This product will cost up to (maximum premium or charge) per (period) if you borrow
the entire credit limit. [The cost depends on your [balance][interest rate].

What is the
maximum benefit
amount?

This product [will pay off your outstanding line of credit][only covers the first (maximum
benefit amount) of the outstanding line of credit][will make your minimum payments of up
to (amount) for (time period)]. [You will be responsible for any balance due above
(maximum benefit amount).]

Can I receive
benefits?

[You may not receive any benefits even if you buy this product.]

How long does the
coverage last?

This product provides coverage for the first (period) of your line of credit [or until you
reach age (age), whichever comes first].

You meet the [age][employment] eligibility requirements [but there are other requirements
that you must meet. If you do not meet these requirements, you will not receive any
benefits even if you buy this product and pay the (period) [premium][charge]].

 Yes, I want to purchase optional (name of product) at a cost of up to (maximum premium or
charge) per (period).
____________________________
[Signature][Initials]

G-16(B) Credit Life Insurance Sample

OPTIONAL COSTS
Option to Purchase Credit Life Insurance
STOP. You do not have to buy Credit Life Insurance to get this line of credit. Go to
www.frb.gov/creditprotectionproducts to learn more about this product.
Do I need this
product?

If you already have enough insurance or savings to pay off this line of credit if you die, you
may not need this product.
Other types of insurance can give you similar benefits and are often less expensive.

How much does it
cost?

This product will cost up to $63 per month if you borrow the entire credit limit. The cost
depends on your balance and interest rate.

What is the
maximum benefit
amount?

This product only covers the first $50,000 of the outstanding line of credit. You will be
responsible for any balance due above $50,000.

Can I receive
benefits?

You may not receive any benefits even if you buy this product.

How long does the
coverage last?

This product provides coverage for the first 10 years of your line of credit or until you
reach age 70, whichever comes first.

You meet the age eligibility requirements, but there are other requirements that you must
meet. If you do not meet these requirements, you will not receive any benefits even if you
buy this product and pay the monthly premium.

 Yes, I want to purchase optional Credit Life Insurance at a cost of up to $63 per month.
____________________________
Signature

G-16(C) Disability Debt Cancellation Coverage Sample

OPTIONAL COSTS
Option to Purchase Disability Debt Cancellation Coverage
STOP. You do not have to buy Disability Debt Cancellation Coverage to get this line of credit. Go to
www.frb.gov/creditprotectionproducts to learn more about this product.
Do I need this
product?

If you already have enough insurance or savings to make payments on this line of credit if
you are temporarily disabled, you may not need this product.
Other types of insurance can give you similar benefits and are often less expensive.

How much does it
cost?

This product will cost up to $42 per month if you borrow the entire credit limit. The cost
depends on your balance and interest rate.

What is the
maximum benefit
amount?

This product will make your minimum payments of up to $2,000 for 6 months.

Can I receive
benefits?

You may not receive any benefits even if you buy this product.

How long does the
coverage last?

This product provides coverage for the first 10 years of your line of credit.

You meet the employment eligibility requirements, but there are other requirements that
you must meet. If you do not meet these requirements, you will not receive any benefits
even if you buy this product and pay the monthly charge.

 Yes, I want to purchase optional Disability Debt Cancellation Coverage at a cost of up to $42 per
month.
____________________________
Signature

G-16(D) Unemployment Debt Suspension Coverage Sample

OPTIONAL COSTS
Option to Purchase Unemployment Debt Suspension Coverage
STOP. You do not have to buy Unemployment Debt Suspension Coverage to get this line of credit. Go to
www.frb.gov/creditprotectionproducts to learn more about this product.
Do I need this
product?

These payments will only temporarily suspend your payments due and will not reduce the
balance you owe. Your balance will actually increase during the suspension period as
interest continues to accumulate.
If you already have enough insurance or savings to make payments on this line of credit if
you are temporarily unemployed, you may not need this product.
Other types of insurance can give you similar benefits and are often less expensive.

How much does it
cost?

This product will cost up to $42 per month if you borrow the entire credit limit. The cost
depends on your balance and interest rate.

What is the
maximum benefit
amount?

This product will make your minimum payments of up to $2,000 for 6 months.

Can I receive
benefits?

You may not receive any benefits even if you buy this product.

How long does the
coverage last?

You meet the age and employment eligibility requirements, but there are other
requirements that you must meet. If you do not meet these requirements, you will not
receive any benefits even if you buy this product and pay the monthly charge.
This product provides coverage for the first 10 years of your line of credit or until you
reach age 70, whichever comes first.

 Yes, I want to purchase optional Unemployment Debt Suspension Coverage at a cost of up to $42
per month.
____________________________
Signature

H-17(A) Credit Insurance, Debt Cancellation Coverage,
or Debt Suspension Coverage Model Form

OPTIONAL COSTS
Option to Purchase (Name of Product)
STOP. You do not have to buy (name of product) to get this loan. Go to (Web site of the Federal Reserve
Board) to learn more about this product.
Do I need this
product?

[These payments will only temporarily suspend your payments due and will not reduce the
balance you owe. Your balance will actually increase during the suspension period as
interest continues to accumulate.]
If you already have enough insurance or savings to [pay off this loan][make payments on
this loan] if you (covered event), you may not need this product.
Other types of insurance can give you similar benefits and are often less expensive.

How much does it
cost?

This product will cost up to (maximum premium or charge) per (period). [The cost
depends on your [loan balance][interest rate].]

What is the
maximum benefit
amount?

This product [will pay off your outstanding loan balance, which is now (outstanding loan
balance)][only covers the first (maximum benefit amount) of the outstanding balance on
your loan] [will make your loan payments of up to (amount) for (period)]. [You will be
responsible for any balance due above (maximum benefit amount).]

Can I receive
benefits?

[You may not receive any benefits even if you buy this product.]

How long does the
coverage last?

This product provides coverage for the first (period) of your loan [or until you reach age
(age), whichever comes first].

You meet the [age][employment] eligibility requirements [but there are other requirements
that you must meet. If you do not meet these requirements, you will not receive any
benefits even if you buy this product and pay the (period) [premium][charge]].

 Yes, I want to purchase optional (name of product) at a cost of up to (maximum premium or
charge) per (period).
____________________________
Signature

H-17(B) Optional Credit Life Insurance Sample

OPTIONAL COSTS
Option to Purchase Credit Life Insurance
STOP. You do not have to buy Credit Life Insurance to get this loan. Go to
www.frb.gov/creditprotectionproducts to learn more about this product.
Do I need this
product?

If you already have enough insurance or savings to pay off this loan if you die, you may
not need this product.
Other types of insurance can give you similar benefits and are often less expensive.

How much does it
cost?

This product will cost up to $118 per month. The cost depends on your loan balance.

What is the
maximum benefit
amount?

This product only covers the first $150,000 of the outstanding balance on your loan. You
will be responsible for any balance due above $150,000.

Can I receive
benefits?

You may not receive any benefits even if you buy this product.

How long does the
coverage last?

This product provides coverage for the first 10 years of your loan or until you reach age
70, whichever comes first.

You meet the age eligibility requirements, but there are other requirements that you must
meet. If you do not meet these requirements, you will not receive any benefits even if you
buy this product and pay the monthly premium.

 Yes, I want to purchase optional Credit Life Insurance at a cost of up to $118 per month.
____________________________
Signature

H-17(C) Disability Debt Cancellation Coverage Sample

OPTIONAL COSTS
Option to Purchase Disability Debt Cancellation Coverage
STOP. You do not have to buy Disability Debt Cancellation Coverage to get this loan. Go to
www.frb.gov/creditprotectionproducts to learn more about this product.
Do I need this
product?

If you already have enough insurance or savings to make payments on this loan if you are
temporarily disabled, you may not need this product.
Other types of insurance can give you similar benefits and are often less expensive.

How much does it
cost?

This product will cost up to $81 per month. The cost depends on your loan balance and
interest rate.

What is the
maximum benefit
amount?

This product will make your loan payments of up to $5,000 for 6 months.

Can I receive
benefits?

You may not receive any benefits even if you buy this product.

How long does the
coverage last?

This product provides coverage for the first 10 years of your loan.

You meet the employment eligibility requirements, but there are other requirements that
you must meet. If you do not meet these requirements, you will not receive any benefits
even if you buy this product and pay the monthly charge.

 Yes, I want to purchase optional Disability Debt Cancellation Coverage at a cost of up to $81 per
month.
____________________________
Signature

H-17(D) Unemployment Debt Suspension Coverage Sample

OPTIONAL COSTS
Option to Purchase Unemployment Debt Suspension Coverage
STOP. You do not have to buy Unemployment Debt Suspension Coverage to get this loan. Go to
www.frb.gov/creditprotectionproducts to learn more about this product.
Do I need this
product?

These payments will only temporarily suspend your payments due and will not reduce the
balance you owe. Your balance will actually increase during the suspension period as
interest continues to accumulate.
If you already have enough insurance or savings to make payments on this loan if you are
temporarily unemployed, you may not need this product.
Other types of insurance can give you similar benefits and are often less expensive.

How much does it
cost?

This product will cost up to $81 per month. The cost depends on your loan balance and
interest rate.

What is the
maximum benefit
amount?

This product will make your loan payments of up to $5,000 for 6 months.

Can I receive
benefits?

You may not receive any benefits even if you buy this product.

How long does the
coverage last?

This product provides coverage for the first 10 years of your loan or until you reach age
70, whichever comes first.

You meet the age and employment eligibility requirements, but there are other
requirements that you must meet. If you do not meet these requirements, you will not
receive any benefits even if you buy this product and pay the monthly charge.

 Yes, I want to purchase optional Unemployment Debt Suspension Coverage at a cost of up to $81
per month.
____________________________
Signature