Application
Please fill out as much as you can, all information in encrypted and secure ๐ if at anytime you have questions about how to fill out this form please contact your agent ๐ฐ
Applicants Full Legal Name
First Name
Last Name
Middle name or initial?
Suffix?
Any Jr? The 1, 2, 3?
Applicants Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicants Phone Number
Please enter a valid phone number.
Applicants Email
example@example.com
Applicants Date of birth?
What type of coverage are you applying for?
Index universal life (IUL)
Living Trust
403 B
Annuity
Amount of coverage?
What is the applicants drivers license number and state?
What is the applicants social security number?
What state OR country were they born in?
Policy owner information
โ ๏ธ Please select โyesโ or โnoโ below โ ๏ธ If โNOโ you must complete this sectionโ ๏ธIf โYESโ the proposed insured / applicant is also the owner, please skip this section to the next section labeled โHEALTH INFORMATIONโ
Is the applicant the owner of this policy?
Yes
No
Policy Owners Name
First Name
Last Name
Policy Owners Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy Owners Phone Number
Please enter a valid phone number.
Policy Owners Email
example@example.com
Policy owners date of birth
ย -
Month
ย -
Day
Year
Policy owner is the person who own the policy not the applicant or insurer themselves
Policy owner social security number
Policy owner is who pays for the policy of not the applicant / insured
Policy owners drivers license number and state
Policy owners State or County of birth
Please provide owners relationship to the applicant / proposed insured and any other information you may find important regarding the relationship between the owner and the applicant
Do you want policy information mailed to the owner and the applicant?
Yes, mail to the owner and the applicant
No, only mail to the owner
No, only mail to the applicant
The owner and the applicant are the same
Health Information ๐ฉบ
Information about the applicant
What is your doctors name?
Doctors Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Doctors Phone Number
Please enter a valid phone number.
Date of last visit?
ย -
Month
ย -
Day
Year
Date
Reason for visit?
What is your weight?
What is your height?
Are you taking, or have you taken, any medications in the past 10 years?
Please list them above ๐๐ป
If yes, please provide for which medical conditions?
Include any diagnosis
For any chronic/ ongoing medical conditions please provide your most current readings/status ๐ฉบ
Diabetic A1c / blood pressure average / blood sugar levels/ cancer stages or remission status as examples of needed information โน๏ธ
Are you awaiting any results for diagnostic test?
Is so please list what test and when you expect the results?
Are you currently physically active?
Do you clean your home, exercise, do yard work, or spend time outdoors?
How many days a week are you active?
Do you or have you used nicotine or tobacco?
Yes I use nicotine or tobacco
Yes I have but I do not currently use nicotine or tobacco
Yes I have but I am currently quitting
No I have not ever used nicotine or tobacco
Do you use illicit substances, such as THC, cannabis, cocaine, heroine, pcp, mdma, fentanyl, ecstasy or any other non prescription drugs?
Yes I use illicit substances regularly
Yes I use but cannabis products only
No I no longer use illicit substances
No I have never used any illicit substances
Do you drink alcohol?
Yes, regularly
Yes, socially
Yes, on occasion
No
Have you ever been advised by a doctor to stop the use of alcohol, substances , or nicotine?
Yes alcohol
Yes substances
Yes nicotine
No
Are you currently in an assisted living, nursing home, or receiving care for your daily routine?
Yes I am in a nursing home
Yes I am in assisted living
Yes I receive care
No
Personal and Employment History
For applicant
Do you plan to travel outside the US?
Yes within the year
Yes after the year
Yes not sure when
No
Does the applicant have any arrest, bankruptcies, issues with law enforcement or judicial systems?
Please list any legal concerns for the past 10 years
What is the applicants employment status?
Please Select
Self Employed
Business Owner
Employed
Military
Unemployed
Retired
Independently Wealthy
What is the name of your/their employer?
How much do you/they make annually?
Okay to estimate
What type of employment or work do you do?
What is your job title?
What is your/their net worth?
Okay to estimate
What is your/their relationship status?
Please Select
Married
Engaged
Domestic Partnership
Divorced
Single
Windowed
What is your/their household annual income?
Okay to estimate you and your partners combined annual income
Beneficiary information
Beneficiaries Name
First Name
Last Name
Beneficiaries Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Beneficiaries Phone Number
Please enter a valid phone number.
Beneficiaries Email
example@example.com
Beneficiaries social security number
Beneficiaries date of birth
What is thier relationship to you/them?
What percentage of benefit will they receive?
All benefits must add to 100%
Do you/they have more than one beneficiary?
Please Select
Yes
No
I have a contingent beneficiary
Contingent beneficiary is someone who would take your beneficiaries place if something was to happen to them. IT IS NOT REQUIRED.
Name any other beneficiaries and the information you have to provide for them, including the amount you wish them to inherit here:
Are they your contingent beneficiary?
Please Select
Yes
No
Contingent ONLY receives benefits if your first beneficiary is no longer alive, or able to receive the benefits.
Family History
Do you have any children? If so what are their ages and do they have any health concerns?
Is your father alive?
Yes
No
Unknown
What is his current age or age of death?
Does he have any health concerns, or did he pass from health related issues?
Is your mother alive?
Yes
No
Unknown
What is her age or age of death?
Does she have any health concerns, or did she pass away from health related issues?
Do you have any siblings?
Yes
No
Unknown
What are the ages of your siblings and do they have any health concerns?
Premium options
How and when you would your insurance premiums drafted?
How often would you like to draft to your premiums?
Please Select
Monthly
Quarterly
Annually
Is there a specific day you would like to start drafting your premiums?
Please Select
Yes
No
As soon as possible
Please match my social security payment day
Please match my pay day
If yes which day?
You can chose to have your payments come out the same day every month like "on the 15 of the month" Or even the same frequency like, "the third Tuesday if the month"
Are you providing a lump sum premium?
Yes
No
I am using a 1035 exchange for my IRA or 401k
If yes what is the amount of the lump sum premium or exchange amount?
Please provide where will the premiums come from
This information is *REQUIRED*. It will be kept safe and secured and will also be used to confirm your identity ๐ฆ
๐๐๐ฆ๐ ๐จ๐ง ๐๐๐๐จ๐ฎ๐ง๐ญ
๐๐จ๐ฎ๐ญ๐ข๐ง๐ ๐๐ฎ๐ฆ๐๐๐ซ
๐๐๐๐จ๐ฎ๐ง๐ญ ๐๐ฎ๐ฆ๐๐๐ซ
๐ ๐ข๐ง๐๐ง๐๐ข๐๐ฅ ๐๐ง๐ฌ๐ญ๐ข๐ญ๐ฎ๐ญ๐ข๐จ๐ง ๐๐๐ฆ๐
How would you like to receive policy information? Chose all that apply
Mail to owner
Mail to applicant
Email to owner
Email to applicant
Email & mail to owner
Email & mail to application
Signature
Thank you!
Your application will now be reviewed and processed by your agent in order to be submitted and approved by the assets company. Please review, and double check all of your information for any errors and click continue when finished โ
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