Application for Life Insurance
Full Legal Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Drivers License Number
Birthdate
-
Month
-
Day
Year
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
-
Month
-
Day
Year
Date
Reason for Last Doctor's Appointment
Name of Primary Beneficiary
Birth Date of Primary Beneficiary
-
Month
-
Day
Year
Date
Social Security Number of Primary Beneficiary
Address of Primary Beneficiary (if different)
Are you subject to any backup withholding?
Yes
No
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.)
Yes
No
If yes, what type and how often?
In the past 3 years have you used marijuana?
Yes
No
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?
Yes
No
Have you ever been refused, rejected, declined, postponed or rated for an application for life insurance?
Yes
No
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)
Yes
No
Is there any life insurance currently pending or in force with other companies on the life of the proposed insured?
Yes
No
Is there any life insurance currently pending or in force with Farm Bureau Life Insurance Company of Michigan?
Yes
No
Will the policy being applied for replace any existing policy?
Yes
No
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 Pain
Palpitations
Fluttering of the Heart
Irregular Heart Rhythm
High Blood Pressure
Heart Murmur
Any other disorder of the heart, heart valves, or blood vessels
Transient ischemic attack (TIA)
Mini Stroke
Paralysis
Depression, Bipolar, Anxiety disorder, Suicide ideation or attempts, or ADHD
Any other mental disorder
Emphysema or Chronic Respiratory Disorder
Cancer
Currently 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 throat
Headaches, Dizziness, or Fainting
Convulsions, Seizure disorder, or Epilepsy
Other nervous system condition
Sleep apnea, Shortness of breath, Persistent Cough, Bronchitis
Pleurisy, Asthma, Allergies, Tuberculosis, or any other lung disorder
Intestinal Bleeding, Ulcer, Colitis, Diverticulitis, or Recurrent Indigestion
Jaundice or Appendicitis
Hernia
Other disorder of the stomach, intestines, pancreas, liver, or gallbladder
Sugar, Blood in the urine, or abnormal urine results
Sexually transmitted disease
Kidney Stones
Other disorders of the kidney, bladder, prostate, or reproductive organs
Thyroid or other endocrine disorders
Neuritis or Sciatica
Rheumatism, Arthritis, or Gout
Inflammation and pain in the joints, muscles, or fibrous tissue, especially Rheumatoid Arthritis
Fibromyalgia or Multiple Sclerosis
Any other disorders of the muscles or bones (including the spine, back, or joints)
Deformity or Amputation
Cysts, Polyps, or Tumors
Anemia or other disorder of the blood
Any 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 consultation
Had an illness, injury, been prescribed medication, or had surgery
Been a patient in a hospital, clinic, sanitorium, or other medical facility
Had an electrocardiogram, X-ray, or other diagnostic test
Been advised to have a diagnostic test or surgery that has not been completed or been advised to be hospitalized
Had 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?
Yes
No
In the past 5 years have you received any driving violations?
Yes
No
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?
Yes
No
Have you ever been convicted of, or are you awaiting trial for any crime including any misdemeanor or any felony?
Yes
No
Have you had any dramatic changes in weight over the past year?
Yes
No
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)?
Yes
No
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?
Yes
No
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?
Yes
No
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)?
Yes
No
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.
Submit
Should be Empty: