First Name
*
Last Name
*
FEIN / SS
Date of birth
Gender
Life app data
Place of Birth (City, State)
Marital Status
Height
Weight
Address
City
*
State
*
Postal code
*
Owner Information
Individual, Living Trust, Pension Plan, Joint ownership, other
Legal Name of the owner
Is there a Contingent Owner?
Legal Name of the contingent owner(s)
Does the proposed insured have a valid driver's license?
Drivers License Number / State / Expiration Date
Is the Proposed insured currently employed?
Employer Name
Length of Employment (years)
Occupation / Duties
Employer Phone Number
Employer Address
Annual Income
Earned and then Unearned income (if any)
Total Assets, Total Liabilities, and Net worth
Secondary Addressee: You have the right to designate a secondary addressee. If designated, this person will be notified of a possible lapse of insurance coverage. If you wish to designate a secondary addressee, please provide the name and address below and return this form to us. PLEASE DESIGNATE ONLY ONE ADDRESSEE
Payor (if other than owner)
Who will be the payor for this policy?
If not owner - Payor Name
Payor's Birth Date
Payor Social Security or EIN
Payor Address
Payor Phone Number
Beneficiary
Beneficiary Type (Primary, Business, Charitable donation, irrevocable, Last will & Test, Pension trust, primary estate, primary living trust, settlement option, testamentary trust)
Name and Relationship
Share %
Beneficiary Type 2
Name and Relationship 2
Share % 2
Beneficiary Type 3
Name and Relationship 3
Share % 3
Beneficiary Type 4
Name and Relationship 4
Share % 4
Describe more beneficiaries and share % you may need
Would you like to designate a Contingent Beneficiary?
Contingent Name and Relationship
Contingent Share %
Contingent Name and Relationship 2
Contingent Share % 2
Contingent Beneficiary Type 3
Contingent Name and Relationship 3
Contingent Share % 3
Describe contingent beneficiaries and share % you may need
Payment terms (how would you like to pay for the premium?)
Existing Life insurance
Do you have any existing individual life insurance policies and/or annuity contracts in force?
If yes, the total amount of existing insurance in force is
1. Company / Policy # / Type (permanent/term) / Amount / Year issued / Replace?
2. Company / Policy # / Type (permanent/term) / Amount / Year issued / Replace?
3. Company / Policy # / Type (permanent/term) / Amount / Year issued / Replace?
4. Company / Policy # / Type (permanent/term) / Amount / Year issued / Replace?
5. Company / Policy # / Type (permanent/term) / Amount / Year issued / Replace?
Do you have any pending individual life insurance policies and/or annuity contracts?
Is the policy applied for intended to replace, in whole or in part, any existing life insurance or annuity?
non-medical questions (yes/no)
In the past year has anyone proposed for insurance used any product containing nicotine? Nicotine includes: cigarettes, cigars, pipe, smokeless tobacco, e-cigarettes, vaporizers, nicotine gum, patch, nasal spray, etc. If “no,” select the answer that best describes tobacco/nicotine product history. *
Have you used, in either synthetic or natural form, marijuana (cannabis) or marijuana products in the past 12 months? If “no,” select the answer that best describes your marijuana or marijuana product history.
had a driver's license revoked or suspended, had three or more moving violations or accidents, or been convicted or pled guilty to driving under the influence of alcohol or drugs? (If yes, give details, DL State, and Driver's License Number.)
Are you or any other person proposed for insurance on active or inactive duty with any branch of the Armed Forces, National Guard or Reserve Unit, entered into a written agreement or will be at a future date? (If “Yes,” complete the Supplement To Application - Military Questionnaire.)
Within the past 2 years, did you fly as a pilot, crew member, or with any duties aboard an aircraft, or is there any intention of doing so within the next 2 years? If "yes", complete an Aviation Supplement.
Within the past 2 years, did you engage in racing, parachuting, or scuba diving or is there any intention of doing so within the next 2 years? If “yes,” complete the applicable Supplement to Application Questionnaire.
Have you ever had a driver’s license suspended or revoked or, within the last 5 years, been convicted of or pled no contest to reckless or negligent driving or driving under the influence of alcohol or drugs?
Have you ever been convicted of, pled guilty or have current charges pending for, a felony or misdemeanor?
Within the next year, do you intend to travel or live outside of the U.S. or Canada? If "yes," complete a Foreign Travel Questionnaire.
Within the past 5 years, have you been declined, withdrawn, or postponed for insurance or had a policy issued other than as applied for?
Are you currently receiving, or within the past 5 years have you received or applied for, any disability benefits, including Worker's Compensation, Social Security Disability, or any other form of disability insurance?
Have you ever used illegal or other habit forming drugs, except as prescribed by a physician, ever received medical treatment or counseling for, or been advised by a physician to reduce or discontinue the use of alcohol and/or non-prescribed drugs? If "yes", complete the Supplement to Application-Alcohol/Drug Questionnaire.
Are all persons proposed for insurance United States Citizens? (If "no," complete the Supplement to Application-Citizenship Questionnaire.)
Has the Applicant (Owner) or any Proposed Insured entered into or have plans to enter into any agreement or contract to sell or assign the ownership of or any beneficial interest in the applied-for policy? If "yes," give details.
Has the Applicant (Owner) or any Proposed Insured ever sold a policy to a life settlement or viatical company, or other secondary market provider? If "yes," give details.
Will any portion of the premiums for this policy be financed? If “yes,” give details.
Will the Applicant (Owner) or any Proposed Insured receive any payment in connection with insurance issued on the basis of this application? If “yes,” give details.
If answering Yes to any of the above questions, please type the number and give detail
Physician Information
Do you have a Personal Physician?
Personal Physician Name / Facility
Physician Address
Physician Phone Number
Physician Fax Number
Do you have an other Personal Physicians (if yes, provide details below)?
Other Physician Details
Medical Information
Have you ever been diagnosed with, treated for, hospitalized for or been advised to seek treatment by a member of the medical profession for any of the following:
High blood pressure, high cholesterol or high triglycerides?
Heart disease or disorder, heart attack, heart failure, heart murmur, angina or chest pain, palpitations, irregular heartbeat or coronary artery disease?
Circulatory system disorder, thrombophlebitis, aneurysm, embolism, peripheral vascular disease or edema?
Chronic headaches, seizures, fainting, dizziness, epilepsy, paralysis, dementia, Alzheimer’s Disease, cognitive impairment, or other nervous system or brain disorder?
Any tumor, masses, cysts, cancer, melanoma, pre-cancerous lesion, lymphoma or disorder of the lymph nodes?
Anemia, leukemia, clotting disorder, or any other blood disorder?
Diabetes or any complications of diabetes, elevated blood sugar, a disorder of the urinary tract or findings of sugar, protein or blood in the urine?
Asthma, emphysema, chronic obstructive pulmonary disease (COPD), shortness of breath, sleep apnea, tuberculosis, sarcoidosis, persistent bronchitis, spitting up blood or any other disorder of the lungs or respiratory system?
Arthritis, gout, fibromyalgia, any disorder of the back, spine, muscles, nerves, bones, joints or skin or a neuromuscular disorder?
Ulcers, colitis (including Ulcerative Colitis), Crohn’s disease, jaundice, hepatitis, cirrhosis, gastrointestinal bleeding, or other disorder of the stomach, esophagus, liver, intestines, gallbladder or pancreas?
Disorder of the testicles, prostate, breasts, ovaries, uterus, cervix, kidney, urinary bladder, kidney failure, reproductive organs, or any complication of pregnancy?
Thyroid, pituitary, or other endocrine or glandular disorder?
Any nervous, mental, emotional, mood, anxiety, depression, PTSD, Bipolar, Schizophrenia, or a psychiatric disorder, or eating disorders?
Lupus, Scleroderma, Multiple Sclerosis (MS), Rheumatoid Arthritis, autoimmune disease, or connective tissue disease?
Carotid artery disease, stroke, mini-stroke or Transient Ischemic Attack (TIA)?
Ever tested positive for exposure to HIV (Human Immunodeficiency Virus) or been diagnosed as having or been trated for AIDS (Acquired Immune Deficiency Syndrome), or any other immune deficiency disorder?
In the past 12 months have you been prescribed any medications other than contraceptives?
Within the past 5 years, have you been treated or examined by a member of the medical profession or been advised by a member of the medical profession to get specified medical care which was not completed, such as any hospitalization, surgery, or diagnostic test, except those tests related to the Human Immunodeficiency Virus ( AIDS virus)?
Has any immediate family member (parents, sisters or brothers) died as a result of, or been diagnosed with, heart disease or cancer prior to age 60?
If answering Yes to any of the above questions, please type the number and give detail:
HIV Consent - Proposed Insured The following information is required to complete the informed consent and authorization form for HIV testing. The form will be presented later in the application process, in its entirety, and your consent is not valid until your signature is placed on the form.
Is Physician same as Personal Physician
Agent of record (who is your agent? or no one)
*
How did you find us?
*
Referral
Agent
TV
Website
LinkedIn
Facebook
Tiktok
Instagram
Other
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