• LIFE INSURANCE

    Digital Application Form

  • About This Form

    This is a universal application used for agency purposes only.

    You will recieve an actual copy of your submitted application to sign directly from the insurance carrier when submitted.

    PRIVACY STATEMENT

    This information will NOT be sold or re-distributed.

    This information will be used only for purposes of obtaining insurance coverage(s) for the porposed insured. Information will be shared only with quoting insurance carriers. 

     

  • Proposed Insured

  • Format: (000) 000-0000.
  •  - -
  • Gender
  • Is the Proposed Insured a U.S. Citizen?

  • Financial Information

  • What is the Proposed Insured's current employment status?
  • Employment Status

  • Additional Information

  • Has an offer been made borrow or be given money, or other property, to pay for or enter into this insurance contract applied for?
  • Has an offer been made to sell, transfer or assign an insurance contract issued as a result of this Application?

  • Are you on active duty military or reserves?
  • Will the Owner be different from the Proposed Insured?

  • I.D. Information

  • Indicate the type of Photo I.D. used to verify identity

  • Lifestyle Questions

  • Within the past 5 years. Used marijuana (more than once a week), heroin, cocaine, a narcotic, a barbiturate, a hallucinogen or another controlled substance except as prescribed by a licensed physician or medical practitioner?
  • Within the past 12 months, have you used tobacco, in any form, or another nicotine product?
  • Have you ever used tobacco, in any form, or another nicotine product?
  • Received or been advised to receive treatment or counseling for, or to discontinue or reduce, the use of alcohol, or a non-prescribed or prescribed drug?

  • Have you flown, or do you intend within the next 2 years to fly, in an aircraft as a student pilot or licensed pilot?
  • Have you engaged, or do you intend within the next 2 years to engage, in motor vehicle or boat racing, mountain or rock climbing, scuba diving, skydiving, ballooning, hang gliding or ultra light flying?
  • Do you expect, within the next 2 years, to change your country of residence or to travel outside of the United States, Canada, Caribbean Islands (excluding Haiti), Western Europe, Hong Kong, Australia or New Zealand?
  • Within the past 5 years, have you had your driver’s license suspended or revoked or been convicted of or pled guilty to more than 3 moving violations or to 1 or more driving while impaired or under the influence violations?
  • Within the past 10 years, have you been convicted of or pled guilty to a felony?
  • Within the past 180 days, have you been unable to work at your regular job for more than 20 consecutive days or are you currently not actively at work due to an injury or sickness?
  • Within the past 10 years, have you been diagnosed with, or received treatment or medication, tested positive or been given medical advice for arthritis or for a disease or disorder of the back, neck or musculoskeletal system?
  • Are you currently on parole, incarcerated, or serving probation or within the past 12 months have you served probation?

  • Coverage

  • Time period of insurance needed.

  • Beneficiary

  • Other Insurance

  • Is there another annuity or life insurance application pending, on the life of the proposed insured, with another insurer?
  • Do you currently have an annuity or life, accidental death, critical illness or disability income insurance pending or in force?
  • Have you ever had an application for life, health, disability or critical illness insurance declined, rated or modified?
  • Will coverage be discontinued or reduced, or premium payments stopped, on existing life insurance coverage or an annuity, if the insurance applied for in this Application is issued (includes military group life insurance)?

  • Physician

  •  - -
  • Were you advised that results of that consultation were outside normal ranges?
  • Is your primary physician different from the last physician consulted?
  • Format: (000) 000-0000.

  • Additional Questions

  • Have you ever been diagnosed with Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or tested positive for Human Immunodeficiency Virus (HIV)?

  • Within the past 2 years, have you?
  • a) Had or been advised to have a test (other than for HIV) such as an EKG, CT scan, bone scan, MRI scan, colonoscopy, echocardiogram, angiogram, biopsy, or endoscopy?
  • b) Been advised to have a check up, consultation, medication, treatment, surgery, hospitalization, lab test or diagnostic test (other than for HIV) that has not yet been started or completed, or the results of which are not yet known?
  • a) Do you reside in a nursing home or skilled nursing facility or psychiatric facility, or are you receiving or been advised to receive, skilled nursing care, hospice care, or home healthcare for a terminal condition that is expected to result in death within the next 12 months or for a chronic condition?
  • b) Do you require the use of a wheelchair due to a chronic illness or disease?
  • c) Do you require assistance with any of the following activities of daily living: taking medications, bathing, dressing, eating, or toileting?
  • d) Within the past 3 years, have you been diagnosed with, or received treatment or medication, tested positive or been given medical advice for sleep apnea, seizures or epilepsy?

  • Within the past 10 years, have you been diagnosed with, or received treatment or medication, tested positive or been given medical advice for the following:
  • a) Diabetes, high blood pressure, coronary artery disease, heart murmur, chest pain, irregular heartbeat, aneurysm, stroke, congestive heart failure (CHF), a disease or disorder of the arteries or valves, (PVD or PAD), or had a heart attack, heart surgery, heart procedure or circulatory surgery?
  • b) Cancer (excluding skin cancer that is basal cell carcinoma), tumor, gastrointestinal bleeding, unexplained weight loss, or a disease or disorder of the pancreas or endocrine system?
  • c) Asthma, emphysema, Chronic Obstructive Pulmonary Disease (COPD), shortness of breath, or a disease or disorder of the respiratory system or do you currently require the use of oxygen equipment?
  • d) Dementia, Alzheimer's disease, paralysis, multiple sclerosis, Parkinson's disease, Lou Gehrig's disease (ALS), muscular dystrophy, fibromyalgia, or a disease or disorder of the brain or nervous system?
  • e) Anxiety, depression, manic depression, bi-polar disorder, schizophrenia or a mental health disorder?
  • f) Blood in the urine, hepatitis, Crohn’s disease, Systemic Lupus, cirrhosis, or a disease or disorder of the liver, prostate, bladder, kidney, genito-urinary organs, connective tissue or the digestive or immune system (other than HIV)?

  • Prescription Medications

  • Are you currently taking prescription medication or under treatment?

  • Within the past 5 years, have you consulted a physician other than previously identified, or a medical practitioner, or been treated, tested or monitored in a clinic, hospital or emergency room?
  • Within the past 4 months, been admitted or been medically advised to be admitted to a hospital or other licensed health care facility (other than for childbirth)?
  • Within the past 4 months, had surgery performed or recommended, had or been medically advised to have a medical test (other than for HIV) or investigation, that has not yet been started or completed, or the results of which are not yet known?
  • Within the past 24 months, had either an investigation or treatment, by a physician or medical practitioner, for chest pain, heart problem, stroke, cancer or AIDS (''Investigation'' does not include negative tests for HIV)?
  • Within the past 10 years, have you been diagnosed with, or received treatment or medication, tested positive or been given medical advice for high cholesterol?

  • Family History

  • Do you have, alive or deceased, a parent or sibling diagnosed with or treated for, prior to age 60, diabetes, heart attack, heart disease, stroke, cancer, polycystic kidney disease, Huntington’s Chorea, or Alzheimer’s?

  • Payments

    Premiums will not be withdrawn until after your policy is approved and issued.
  • Payment mode:

  • AND THAT'S IT

    We hope that was easy! 

    Please proceed to submit

    By clicking "Submit " The proposed insured has given permission to: 

    Use this information for purposes of obtaining insurance coverage(s) for the proposed insured. This information will be submitted to insurance carriers for underwriting purposes only. 

    By submitting this form, you acknowledge and authorize the use and disclosure of your personal health information (PHI) as required for life insurance underwriting purposes. This may include sharing your information with insurance carriers, reinsurers, medical providers, and third-party service partners involved in evaluating your application.

    All information provided will be kept confidential and used solely for the purpose of obtaining life insurance coverage. We follow strict privacy and security protocols to protect your data, in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and all applicable privacy laws. Your authorization is voluntary, but necessary to proceed with your application. You may revoke your authorization at any time by notifying us in writing, except to the extent that action has already been taken in reliance on it.

    I agree to receive emails, text messages, and phone calls, which may be recorded and/or sent using automated dialing or emailing equipment or software, unless I opt-out from such communications. I also agree to the Terms of Use and Privacy Policy above. I understand that my consent to be contacted is not a requirement to purchase any product or service and that I can opt out at any time. Message & data rates may apply. Message frequency varies.

  • Should be Empty: