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)

Has the Proposed Insured:
Applied for or received disability benefits in the last 5 years?
Applied for life or health insurance that was declined, postponed, or modified, or had reinstatement of an insurance policy denied?
Flown as a pilot or crew member within the last 2 years, or does the Proposed Insured intend to do so in the next two years?
Had more than 2 moving motor vehicle violations in the last 3 years?
Had his or her driver's license in a state of revocation, restriction, or suspension or had a driving while intoxicated or driving under the influence of alcohol or drugs violation in the last 5 years?
Engaged in scuba diving, auto or motorcycle racing, rock or mountain climbing, ultra light flying, hang gliding, or shy diving in the last 2 years, or does the Proposed Insurd intend to do so in the next two years?
Traveled outside the United States or Canada in the last 2 years, or does the Proposed Insured intend to do so in the next 2 years?
Are you a member or have you entered into a written agreement to become a member of the United States Armed Forces?
Been put on alert for or had active duty military service outside the United States or Canada within the last 2 years?
Been convicted, plead guilty or placed on probation or parole for the commission of any criminal offense in the last 10 years other than a motor vehicle violation or is the propsed insured currently awaiting trial for such an offense?
Intended for any party other than the owner to obtain any right , title, or interest in any policy issued on the life of the Proposed Insured as a result of this application?
Is the Proposed Insured a United Stated citizen, Canadian citizen or a lawful permanent resident of the United States (Permanent Residence Card/green card holder)?

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

Does the Proposed Insured have a family history (parents) of heart disease, stroke or cancer other than basal cell carcinoma?
In the Past 5 Years has the Proposed Insured:
Used any controlled substance, such as cocaine, heroin, narcotics, amphetamines, barbituarates, sedatives, hallucinogens, or marijuana without a medical prescription?
Been diagnosed with alcoholism or drug dependence by a member of the medical profession or received treatment, advice, or counseling from any physician, counselor, or other medical provider or joined or participated in an organization or support group for use of alcohol or drugs?
Has the Proposed Insured EVER been diagnosed with, treated or tested positive for, or been given medical advice by a member of hte medical profession for:
Fainting spells, severe headaches, paralysis, stroke, epilepsy, depression or other mental illness or any disease or disorder of the brain or nervous system?
Any breathing disorder including asthma, chronic obstructive pulmonary disease (COPD), sleep apnea, or any disease or disorder of the lungs or respiratory system?
Any disease or disorder of the stomach, esophagus, colon, intestines, liver, glands or digestive system?
High blood pressure, chest pain, heart attack, heart murmur, anemia, or any disease or disorder of the blood heart or circulatory system?
Diabetes, kidney disease or disorder, or sugar, albumin, or blood in the urine?
Arthritis, lupus, or any disease or disorder of the back, bones, joints or muscles?
Cancer, leukemia, tumor, or polyp
Any sexually transmitted disease (STD)?
Any impairment of hearing or sight, except for the need of corrective lenses?
Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Syndrome (AIDS) or tested positive for anti-bodies to the AIDS virus (except by a home testing kit)?
A weight loss of 15 pounds or more in the past 12 months (except for pregnancy-related weight loss)?
Is the Proposed Insured now pregnant?
Has the Proposed Insured been prescribed or taken any medication in the last 12 months?

Agent of record (who is your agent? or no one) *

How did you find us? *