Application for Life Insurance

Application for Life Insurance
Full Legal Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
By providing your phone number, you agree to receive text messages from the Patrick Coffey Agency. You may opt out of text messaging at any time. Message & data rates may apply. Message frequency varies.
Email
example@example.com
Drivers License Number
Birthdate

MonthDayYear
Date
Social Security Number
Annual Income
Net Worth
Amount of Life Insurance Currently in Force
Spouse Annual Income (If Applicable)
Spouse Life Insurance Currently in Force (If Applicable)
Birth City
Occupation
Occupational Duties
Name of Current Doctor/Clinic
City of Doctor/Clinic
Height
Weight
Date of Last Doctor's Appointment

MonthDayYear
Date
Reason for Last Doctor's Appointment
Name of Primary Beneficiary
Birth Date of Primary Beneficiary

MonthDayYear
Date
Social Security Number of Primary Beneficiary
Address of Primary Beneficiary (if different)
Are you subject to any backup withholding?

YesNo
In the past 3 years, have you used any nicotine products in any form (cigarettes, cigars, pipes, chewing tobacco, e-cigarettes, hookah, gum, patches, etc.)

YesNo
If yes, what type and how often?
In the past 3 years have you used marijuana?

YesNo
If yes, what type and how often?
In the past 5 years, have you filed for bankruptcy, and/or had a tax lien or judgement filed against you?

YesNo
Have you ever been refused, rejected, declined, postponed or rated for an application for life insurance?

YesNo
In the next 2 years do you have any plan of foreign travel or residence outside of the US or Canada? (tickets must currently be purchased)

YesNo
Is there any life insurance currently pending or in force with other companies on the life of the proposed insured?

YesNo
Is there any life insurance currently pending or in force with Farm Bureau Life Insurance Company of Michigan?

YesNo
Will the policy being applied for replace any existing policy?

YesNo
To the best of your knowledge and belief, have you ever been treated for or been diagnosed by a member of the medical profession as having: (check all that apply)

Chest PainPalpitationsFluttering of the HeartIrregular Heart RhythmHigh Blood PressureHeart MurmurAny other disorder of the heart, heart valves, or blood vesselsTransient ischemic attack (TIA)Mini StrokeParalysisDepression, Bipolar, Anxiety disorder, Suicide ideation or attempts, or ADHDAny other mental disorderEmphysema or Chronic Respiratory DisorderCancerCurrently Pregnant (if applicable)
Please provide a brief explanation for any of the boxes that are checked.
In the past 5 years, have you been treated for, or had any indication of: (check all that apply)

Abnormalities of the eyes, ears, nose, or throatHeadaches, Dizziness, or FaintingConvulsions, Seizure disorder, or EpilepsyOther nervous system conditionSleep apnea, Shortness of breath, Persistent Cough, BronchitisPleurisy, Asthma, Allergies, Tuberculosis, or any other lung disorderIntestinal Bleeding, Ulcer, Colitis, Diverticulitis, or Recurrent IndigestionJaundice or AppendicitisHerniaOther disorder of the stomach, intestines, pancreas, liver, or gallbladderSugar, Blood in the urine, or abnormal urine resultsSexually transmitted diseaseKidney StonesOther disorders of the kidney, bladder, prostate, or reproductive organsThyroid or other endocrine disordersNeuritis or SciaticaRheumatism, Arthritis, or GoutInflammation and pain in the joints, muscles, or fibrous tissue, especially Rheumatoid ArthritisFibromyalgia or Multiple SclerosisAny other disorders of the muscles or bones (including the spine, back, or joints)Deformity or AmputationCysts, Polyps, or TumorsAnemia or other disorder of the bloodAny other disease or disorder not listed above
Please provide a brief explanation for any of the boxes that are checked.
Other than previously indicated, have you within the past 5 years: (check all that apply)

Had a checkup or consultationHad an illness, injury, been prescribed medication, or had surgeryBeen a patient in a hospital, clinic, sanitorium, or other medical facilityHad an electrocardiogram, X-ray, or other diagnostic testBeen advised to have a diagnostic test or surgery that has not been completed or been advised to be hospitalizedHad any other disease, disorder, or impairment not previously mentioned for which you have sought medical treatment
Please provide a brief explanation for any of the boxes that are checked.
In the past 5 years have you participated in sky diving, soaring or parachuting, diving, motorized racing, or any other hazardous sport or activity?

YesNo
In the past 5 years have you received any driving violations?

YesNo
If yes, what kind of driving violation and when did the violation occur?
Have you ever applied for or received a pilot's license or certification, or a student pilot's license or certification?

YesNo
Have you ever been convicted of, or are you awaiting trial for any crime including any misdemeanor or any felony?

YesNo
Have you had any dramatic changes in weight over the past year?

YesNo
Has there been a family history of heart disease, diabetes, cancer, polycystic kidney disease, Huntington's disease, or any other heriditary disorder in your immediate family (father, mother, siblings)?

YesNo
To the best of your knowledge and belief, have you ever been treated for or been diagnosed by a member of the medical profession as having diabetes, stroke, coronary artery disease, heart attack, hepatitis, or HIV/AIDS?

YesNo
Have you ever been convicted of an alcohol related violation in the last 3 years, or have you ever been convicted of more than one alcohol related violation?

YesNo
Have you ever been treated for or been diagnosed by a member of the medical profession for alcoholism, alcohol abuse, or used any drugs not prescribed by a physician (other than marijuana)?

YesNo
Please provide a brief explanation for any question answered 'yes'.
Are your parents still living? If yes, please provide the age of each living parent. If either are deceased, please provide the age that they passed away.
Do you have any siblings? If yes, please provide the age of each living sibling. If any are deceased, please provide the age that they passed away.
To the best of my knowledge and belief, the above attestations are true and correct.

Clear
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