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Life Insurance Application
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Name
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First
Last
Address
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City
State
Zip Code
Country
Phone Number
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Email
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General Information
Social Security Number
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Date of Birth
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Are you a U.S. Citizen?
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Choose
Yes
Permanent Resident
Drivers License Number
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Drivers License State Issued
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Primary Physician Information
Name
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First
Last
Address
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City
State
Zip Code
Country
Phone Number
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Date and reason of last visit?
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Were any tests performed? Or any treatments received?
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Lifestyle Information
Have you ever used Cigarettes, nicotine patches, nicotine gum, or other nicotine subsitutes?
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Never
Cigarettes
Nicotine Patch
Nicotine Gum
Chewing tobacco
Cigar
Pipe
Other
If Yes, was the use of the product within:
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Last 12 months?
Last 24 months?
Last 36 months?
Last 60 months?
60 plus months?
If you have used tobacco in pipe or cigar form in the last 12 months how often?
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Daily
Weekly
Monthly
Less than Monthly
It was a one time thing.
Replacement Information
Are you canceling another life insurance policy so that you can purchase this one?
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Choose
Yes
No
If so, what is the name of the Company you are cancelling?
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Military Information (including National Guard and Reserves)
Are you a member of the Military?
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Yes
No
Underwriting information
In the past 10 years, as the proposed insured:
Used barbiturates, hallucinatory drugs, narcotics, including crack, ecstasy, opium derivatives, marijuana, LSD, PCP, or any derivatives of these drugs, or been advised by a licensed medical professional to get medical treatment or undergone any medical treatment, counseling or hospitalization for drug abuse?
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Yes
No
Been advised by a licensed medical professional to limit your alcohol use or been advised to get medical treatment, or undergone any medical treatment or counseling or hospitalization for alcoholism, excessive alcohol use or abuse? Or, have you subsequently consumed alcohol after receiving counseling or medical treatment for alcohol use? Or, drink on average more than 3 alcoholic drinks per day?
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Yes
No
Had your driver’s license revoked or suspended or been convicted of reckless driving, driving without a valid license, or for driving while under the influence of alcohol or drugs (DWI, DUI)?
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Yes
No
Pled guilty to or been convicted of a felony or misdemeanor? If yes, provide details on the nature of the plea or conviction, the date and state where the plea or conviction occurred, and whether time was served in prison
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Yes
No
Been refused for life insurance or charged an extra premium for life insurance?
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Yes
No
Have you ever:
Within the past five years, had his/her driver’s license revoked or suspended or been convicted of reckless driving, driving without a valid license, or for driving while under the influence of alcohol and/or drugs (DWI, DUI)?
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Yes
No
Within the past five years, had more than one speeding violation or, motor vehicle moving violation, been involved in any accident in which he/she was found to be at fault, or pled guilty or been convicted for driving under the influence of alcohol?
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Yes
No
Flown a plane in the past 24 months or plan to fly in the next 12 months as a pilot, copilot, student pilot, military pilot, engineer or in any other capacity except as a regularly scheduled commercial airline pilot or fare-paying passenger?
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Yes
No
In the past 12 months or in the next 12 months, engaged in or plan to engage in the following recreational activities: hang gliding, skydiving, motor vehicle/cycle racing, rock climbing, ballooning, bungee jumping, mountain climbing, motor boat racing, snowmobile racing, ultra light aircraft flying, scuba diving to more than 50 feet in depth, or in caves, ship wrecks or deep seas?
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Yes
No
Had or have any bankruptcy pending or expect to file bankruptcy in the next 12 months?
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Yes
No
Comment
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Medical Questions
In the past 10 years, as any person proposed for insurance and diagnosed by a licensed medical professional, treated word vies to get medical treatment from a licensed medical professional, hospitalized, or presently taking prescription drugs for any the following diseases or disorders;
Angina, chest pain, heart attack, heart or your, heart surgery, your regular heartbeat, abnormal EKG, coronary artery bypass, angioplasty, stents, career field ask your disease, poor circulation, valvular heart disease, cardiomyopathy or heart murmur?
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Yes
No
High blood pressure, hypertension or abnormal cholesterol levels?
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Yes
No
Stroke, seizures, epilepsy, dizziness, thinking, memory disorder or any other neural logical or brain disorder?
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Yes
No
Disorder of the kidney, bladder or urinary system, abnormal PSA, abnormal PAP smear without subsequent normal PAP smear or protein or blood in the urine?
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Yes
No
Anemia, hemophilia, clotting disorder of the blood?
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Yes
No
Depression, anxiety, stress, eating disorder or any other nervous, mental or emotional condition?
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Yes
No
Multiple sclerosis, and rightists, and rapidly, paralysis, muscular dystrophy, Parkinson's disease or any other disorder of the muscles?
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Yes
No
Arthritis, chronic pain, fibromyalgia, connective tissue disease, lupus or scleroderma?
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Yes
No
Cancer, malignancy, tumor, Mono, and Bouma, Hodgkin's disease or leukemia?
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Yes
No
Diabetes, abnormal blood sugar, sugar in the urine, disease or disorders of the Adrenal, parathyroid, Pituitary or thyroid glands?
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Yes
No
Immune deficiency disorder ( acquired immune deficiency syndrome ( Aids ) or AIDs related complex (ARC)?
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Yes
No
Colitis, ulcerative colitis, Crohn's, esophageal varices, peptic or gastric ulcer, intestinal or rectal bleeding, diverticulitis, colon polyps, cirrhosis, Titus, liver failure, liver impairment, loss of bowel function or other disease or disorder of the liver or Pancreas?
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Yes
No
Other than indicated above, has the proposed insured:
In the past five years, been diagnosed, treated or devised to get medical treatment from a licensed medical professional for any mental or physical disorder or medically or surgically treated condition not listed above?
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Yes
No
Had a parent or sibling who before age 60 was diagnosed with or died from cardiovascular disease, stroke, cancer except basil or squall must sell cancer of the skin, Huntington's Chorea, familial polyposis or polyposis or polycystic kidney disease?
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Yes
No
Had a weight gain or loss of 10 or more pounds within the past 12 months for any reason other than pregnancy?
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Yes
No
Is the proposed insured currently receiving or have an application pending for any illness or disability benefits or compensation?
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Yes
No
Except or tests related to human immunodeficiency virus AIDS virus, in the past 12 months been advised by a licensed medical prof EKG, x-ray, blood or urine test or any other diagnostic test, or sought medical device or treatment for any reason?
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Yes
No
In the past 12 months been advised by a licensed medical professional to be admitted to a hospital, medical facility, nursing home or assisted living facility?
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Yes
No
Is the proposed insured currently taking any prescription medications, herbal remedies or nonprescription medications for any disease or disorder not listed above?
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Yes
No
If you have answered YES to any of the above questions,
please provide details in the comments section below!
Comments
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Beneficiary Information
Primary Beneficiary
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Last
Address
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Relationship to Insured
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Percentage
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100%
Primary Beneficiary
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Relationship to Insured
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Select One
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10%
20%
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40%
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60%
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80%
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100%
If you have Contingent beneficiaries please list them in the comments section below.
Comment
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It is declared the statements and answers in this application, including statements by the Proposed insured in any medical questionnaire or supplement that become part of this application, are complete and true to the best knowledge and belief of the undersigned. If you believe this to be true please type your name in the space below.
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Submit
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