LIFE INSURANCE [DIGITAL]

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
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com

Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Country of Birth
Is the Proposed Insured a U.S. Citizen?

YesNo
Primary Language

Financial Information
What is the Proposed Insured's current employment status?

EmployedRetiredHome MakerUnemploymentDisabledStudent
Employment Status

Full TimePart TimeSeasonal
Occupation
Duties
Income (Past 12 months): $

Has an offer been made for any of the following?
Borrow or be given money, or other property, to pay for or enter into this insurance contract applied for?

YesNo
Sell, transfer or assign an insurance contract issued as a result of this Application?

YesNo

Are you on active duty military or reserves?

YesNo
Will the Owner be different from the Proposed Insured?

YesNo
If "YES" checked. Name proposed owner of policy.

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

DLPassPortGovernment ID
Driver's License No.
Issue State
Social Security Number

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?

YesNo
Within the past 12 months, have you used tobacco, in any form, or another nicotine product?

YesNo
Have you ever used tobacco, in any form, or another nicotine product?

YesNo
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?

YesNo

Lifestyle Questions
Have you flown, or do you intend within the next 2 years to fly, in an aircraft as a student pilot or licensed pilot?

YesNo
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?

YesNo
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?

YesNo
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?

YesNo

Within the past 10 years, have you been convicted of or pled guilty to a felony?

YesNo
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?

YesNo
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?

YesNo
Are you currently on parole, incarcerated, or serving probation or within the past 12 months have you served probation?

YesNo

Coverage
Time period of insurance needed.

10 years15 years20 years25 years30 yearsPermanent coverageNot Sure
Desired premium amount per month.
Amount of death benefits wanted.

Beneficiary
1-Name

First NameLast Name
Relationship to Proposed Insured
DOB
Percentage

2-Name

First NameLast Name
Relationship to Proposed Insured
DOB
Percentage

Additional Beneficiary Information

Other Insurance
Is there another annuity or life insurance application pending, on the life of the proposed insured, with another insurer?

YesNo
Do you currently have an annuity or life, accidental death, critical illness or disability income insurance pending or in force?

YesNo
Have you ever had an application for life, health, disability or critical illness insurance declined, rated or modified?

YesNo
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)?

YesNo

Physician
Date you last consulted a physician:

MonthDayYear
Date
Reason(s): Why/Outcome
Were you advised that results of that consultation were outside normal ranges?

YesNo
Is your primary physician different from the last physician consulted?

YesNo
Do you have a primary care physician?
Name of primary physician?
Address of primary physician?
Phone Number
Please enter a valid phone number.

Your Height:
Your Weight:

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)?

YesNo
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?

YesNo
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?

YesNo

Do you currently?
a) 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?

YesNo
b) Require the use of a wheelchair due to a chronic illness or disease?

YesNo
c) Require assistance with any of the following activities of daily living: taking medications, bathing, dressing, eating, or toileting?

YesNo
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?

YesNo

Prescription Medications
Are you currently taking prescription medication or under treatment?

YesNo
Medications Name-dosage-Aliments

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?

YesNo
Parents/Siblings

Payments

Premiums will not be withdrawn until after your policy is approved and issued.
Payer is
Bank
Account Number
Bank Routing/ABA
Payment mode:

monthlyquarterlysemi annuallyannually

AND THAT'S IT

We hope that was easy!

Please proceed to 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.

This information will NOT be sold or distributed.

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.
Proposed Insured consent*

YesNo
Name of primary insured?*

First NameLast Name
Date

MonthDayYear
Date
Name of your representative?
Should be Empty:

LIFE INSURANCE

Proposed Insured

Financial Information

I.D. Information

Lifestyle Questions

Lifestyle Questions

Coverage

Beneficiary

Other Insurance

Physician

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:

Prescription Medications

Has the Proposed Insured:

Family History

Payments