Life Insurance Application

Life Insurance Application
Questions Regarding the Proposed Insured

The person who will be covered by a life insurance policy.
Name of Proposed Insured

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your mailing address the same as your physical address?

YesNo
Mailing address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Social Security Number*
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Birth State
Examples: Oklahoma, Texas
Country of Birth
Examples: United States, Mexico,
Age
Gender

FemaleMale
Height
Weight
Have you gained or lost weight during the last 12 months?
If so, explain with the amount.

Employment Information

For proposed Insured
Occupation
What you do for a living
Employers Name
How long have you worked there?
What are your job duties?
Within the past 5 years have you worked less than full time, received or applied for disability or worker's compensation?
Do you have any other life insurance policy's? If so, how much is it worth?
Within the past 12 months have you applied for or do you have any applications pending for life insurance or disability insurance?

YesNo
What is your net worth?
How much a person owns (their assets) minus what they owe to others (liabilities).
Annual income of insured.
what is your household net worth?

Health Questions

For Proposed Insured
Name of Primary Doctor.
Address of Primary Doctor.
When was the last time you saw your primary or family doctor?
Estimated Month and Year.
What was the visit for?
Examples: Check up, blood work, flu, ect..
What was the outcome of the visit?
Do you use any tobacco products?

YesNo
Have you used any type of products containing tobacco or Nicotine in the last 5 years?

YesNo
Have you used MEDICAL Marijuana in the last 10 years?

YesNo
If you have been prescribed medical marijuana in the last 10 years, what was it used for, and what is the name of the doctor who prescribed it?
Please list all the surgeries you've had in your lifetime.
List of ALL prescribed medications you use DAILY. Describe what the medication(s) are used for and their dosage. Please include the name of the doctor who prescribed each one.
Example: Lipitor. Used for high cholesterol. 20 mg Dr. Woolf
List of medications you use as NEEDED. Describe what the medication(s) are used for and their dosage. Please include the name of the doctor who prescribed each one.
Albuterol. Used for asthma. 90 mcg. Dr. Woolf
(NOT INCLUDING ANY MEDICATIONS LISTED ABOVE) List of medications that have been prescribed in the last 5 years. Describe what the medication(s) were used for. If you still know the dosage please include it. Please include the name of the doctor who prescribed each one.
Even if you haven't taken it in a long time.

Family History

Questions Regarding the Proposed Insurer's Family
Is your father still living?

YesNo
If not, at what age did he pass away?
What was the reason for his passing?
Fathers Age
Is your mother still living?

YesNo
If not, at what age did she pass away?
What was the reason for her passing?
Mothers Age
Have you had any siblings pass away? If so, please tell the reason for each of them.
Has a parent or sibling been diagnosed or treated by a health professional for cancer, heart disease, Huntington's Disease or polycystic kidney disease?

YesNo

Questions Regarding the Owner of the Policy

The person who has ownership of the policy is usually the person who pays the monthly premium. They are able to change the beneficiary as they see fit.
Is the owner of the policy also the proposed insured?

YesNo
Name of the OWNER of the policy

First NameMiddle NameLast Name
Relationship to the Proposed Insured.
Date of Birth

MonthDayYear
Owners Date of Birth
Gender

FemaleMale
Social Security Number
SSN of the Owner
Address of the Owner

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Questions about the Beneficiary

The person who receives the death benefit.
Name of Primary Beneficiary
Person who receives the death benefit. Include middle name.
Social Security Number
(Primary Beneficiary)
Date of Birth

MonthDayYear
(Primary Beneficiary)
Address
(Primary Beneficiary)
Relationship
The proposed insured to the primary beneficiary
Percentage of death benefits going to primary beneficiary.
Name of Second Primary Beneficiary (Optional)
Only if you want to split the death benefit between two people.
Percentage of death benefits going to the SECOND PRIMARY Beneficiary.
Optional. ONLY FILL THIS OUT IF YOU ARE SPLITTING THE DEATH BENEFIT BETWEEN TWO PEOPLE.
Social Security Number
(Second Primary Beneficiary)
Date of Birth

MonthDayYear
(Second Primary Beneficiary)
Address
(Second Primary Beneficiary)
Relationship
Proposed Insured to Second Beneficiary
Contingent Beneficiary

The person who is next in line for the death benefit.
Name of Contingent Beneficiary
This is the person next in line to receive the death benefit if the primary beneficiary(s) passes away.
Date of Birth

MonthDayYear
(Contingent Beneficiary)
Social Security Number
Contingent Beneficiary
Address
Contingent Beneficiary
Phone Number
Please enter a valid phone number.
Relationship
Proposed Insurer to Contingent Beneficiary

Banking Information
Billing Type

Electronic Fund TransferPaper Bill
Premium Frequency

MonthlyAnnualSemi-AnnualQuarterly
Name of Bank
Bank Routing Number
Bank Account Number
Please double check both numbers are correct
Type of Account

CheckingSavings
Drivers License Upload

Can also text me a picture to my phone.
Cancelof
Drivers License Number
I Type First and Last Name certify that to the best of my knowledge and belief the answers on the application are true and correct.
Signature (Draw with Finger)

Clear
Should be Empty:

Life Insurance Application

Questions Regarding the Proposed Insured

Employment Information

Health Questions

Health History

General Questions

Family History

Questions Regarding the Owner of the Policy

Questions about the Beneficiary

Contingent Beneficiary

Banking Information