Medical / Life Insurance Application
Section 1 for Medical - Section Two & Three for Life Insurance - Section 4 to Submit.
Type of Medical Policy
Please Select
Medical
Dental
Vision
Dental / Vision
Name of proposed insured
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Birth Date
*
-
Month
-
Day
Year
Date
Applicants Social Security Number
*
Racial Identity
*
Please Select
African American
White
Hispanic
Asian / Hawaiian
Indian / Native American
Other
Will you be filing taxes for 2024?
*
Yes
No
Are you married?
*
Yes
No
If so please list Name, Birthday, Social Security Number, Relationship to you.
Is there anyone in the house under the age of 19?
*
Yes
No
If so please list Name, Birthday, Social Security Number, Relationship to you.
Place of employment and Phone Number.
*
Annual Income ( Yearly or Monthly)
*
Are you currently Pregnant?
*
Yes
No
Do you currently have Employer Sponsored Medical Insurance?
*
Yes
No
Do you need help with daily task like showering, cooking etc?
*
Yes
No
Any know medical issues?
Back
Next
Life Insurance Medical History
In the past 10 years have you ever been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for:
Type of Policy
Please Select
Whole Life (Guaranteed Entire Lifetime)
Term Life (Limited Period of Time)
Final Expense (Funeral and other Final Expenses)
Indexed Universal Life (Permanent w Cash Value)
For Term Life Policy please chose a time frame
Please Select
10 Year
15 Year
20 Year
25 Year
30 Year
35 Year
40 Year
If this policy if for a child, spouse or loved one please list Name, Birthday, and social security number here.
Please list benefit amount requested.
Accidental Death Rider (This rider gives your loved ones access to a larger cash payment, or “death benefit,” if you die in a covered accident)
Yes
No
Children's Term Rider (A child rider is an add-on to a life insurance policy that pays out a death benefit if one (or more than one) of your children passes away.)
Yes
No
If yes to child rider please list Childs Name, Birthdate and Social Security Number
First Beneficiary Amount
100%
50%
Beneficiary Name
First Name
Last Name
Beneficiary Birth Date
-
Month
-
Day
Year
Date
Beneficiary SSN
Beneficiary Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Second Beneficiary Amount
100%
50%
Beneficiary Name
First Name
Last Name
Beneficiary Birthdate
-
Month
-
Day
Year
Date
Beneficiary SSN
Beneficiary Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the applicant currently have an life threatening illness?
Yes
No
If so please list below
Within the past 12 months have you applied for or do you have any applications pending for life or disability insurance?
Yes
No
Is the policy or rider being applied for replacing any inforce life insurance or annuity contract(s) including long term care insurance, disability income insurance or riders?
Yes
No
Is the Proposed Insured or Owner considering using funds from an inforce life or annuity contract to fund the policy or rider being applied for?
Yes
No
During the last 5 years have you plead guilty to or been convicted of any moving vehicle violations or DUI or have you had a suspended license?
Yes
No
Within the past 10 years, have you been convicted of, or are you currently charged with, a felony or misdemeanor, or are you currently on parole or probation?
Yes
No
Have you been or are you currently involved in any bankruptcy proceedings that have not been discharged? (If yes, provide type & date discharged)
Yes
No
Do you participate in any type of racing, scuba diving, aerial sports, mountain climbing, BASE or bungee jumping, or cave exploration?
Yes
No
Do you participate in any aviation activity other than as a fare paying passenger?
Yes
No
During the next 2 years, do you intend to live or travel outside of the United States?
Yes
No
Have you been offered any cash incentive or other consideration (such as free insurance) as an inducement to apply for or become an insured under this life insurance policy?
Yes
No
Have you been involved in any discussions about the possible sale or transfer of this policy to an unrelated third party, such as (but not limited to) a life settlement company or investor group?
Yes
No
Are you currently taking, or have you taken within the last 12 months, any prescription medications or over the counter drugs, including aspirin and/or herbal supplements?
Yes
No
Within the last 5 years have you used any product containing tobacco or nicotine, including but not limited to cigarettes, ecigarettes, vape pens, cigars, pipes, chewing tobacco, snuff, nicotine gum and/or nicotine patch?
Yes
No
Do you currently have a life policy with another company?
Yes
No
Back
Next
Do you currently have a primary care physician?
Yes
No
Height and Weight
Name of your health care provider
First Name
Last Name
Address of medical care facility and/or health care provider
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date last Seen?
-
Month
-
Day
Year
Date
Any disorder or abnormal condition of the heart, including irregular heartbeat, murmur, rheumatic fever, coronary artery disease, heart attack, chest pain, angina, high blood pressure, or high cholesterol?
Yes
No
Any disorder or abnormal condition of the circulatory or vascular system, including aneurysm, transient ischemic attack, stroke, carotid artery or arterial disease?
Yes
No
Any disorder or abnormal condition of the lungs or respiratory system, including sleep apnea, shortness of breath, asthma, bronchitis, emphysema, chronic obstructive pulmonary disease, tuberculosis, or allergies?
Yes
No
Any disorder or abnormal condition of the lungs or respiratory system, including sleep apnea, shortness of breath, asthma, bronchitis, emphysema, chronic obstructive pulmonary disease, tuberculosis, or allergies?
Yes
No
Any disorder or abnormal condition of the brain or nervous system, including seizures/epilepsy, tremors, falls or imbalance, fainting, dizzy spells, headaches or migraines, loss of consciousness, confusion or memory loss, paralysis, numbness, or any condition which causes limited motion?
Yes
No
Any disorder or abnormal condition of the eyes, ears, nose, throat, or sinuses?
Yes
No
Any disorder or abnormal condition of the endocrine system, including thyroid, pituitary, adrenal or other gland?
Yes
No
Any disorder or abnormal condition of the spine, hip, knee, shoulder, back, joints, bones, muscles, arthritis, rheumatism or gout?
Yes
No
Any disorder or abnormal condition of the urinary system, including bladder, kidney, or urinary abnormalities such as protein, sugar or blood in urine?
Yes
No
Any disorder or abnormal condition of the genital system, including prostate, testicles, pelvic organs, ovaries, cervix, uterus, or breast?
Yes
No
Any disorder or abnormal condition of the skin, including psoriasis, eczema, non-healing wounds, melanoma, nevi or moles? Yes No
Yes
No
Any depression, anxiety, bipolar, schizophrenia, Attention Deficit Disorder (ADD), autism, Down Syndrome or any other developmental or psychological condition including Alzheimer's, dementia, or Post Traumatic Stress Disorder (PTSD)?
Yes
No
Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS), or have you tested positive for exposure to or been diagnosed with HIV or AIDS?
Yes
No
Any cancer, tumor, polyp, lump, nodule, cyst, lymphoma or any disorder of the lymph nodes?
Yes
No
Diabetes, high blood sugar, pre-diabetes, impaired glucose tolerance, impaired fasting glucose, insulin deficiency, hyperglycemia, or diabetes associated with pregnancy?
Yes
No
Amputation due to disease or other medical condition?
Yes
No
Ataxia, transverse myelitis, myasthenia gravis, autoimmune disorder such as lupus, blindness, or post-polio syndrome?
Yes
No
Parkinson's disease, muscular dystrophy, Huntington's chorea, motor neuron disease, Lou Gehrig's Disease (ALS), or multiple sclerosis?
Yes
No
In the past 10 years have you used marijuana, cocaine, heroin, or any other illicit drug or controlled substance, been advised by a physician to discontinue or reduce alcohol or drug intake, used drugs not prescribed by a physician, been self-admitted to a drug or alcohol treatment facility, or been a member of a support group such as NA or AA?
Yes
No
Within the past 5 years have you: a. Consulted with a physician other than your personal physician or had x-rays, electrocardiograms, heart catheterization, mammograms, ultrasounds, biopsy, or any other medical tests and/or procedures, except those related to the Human Immunodeficiency Virus (AIDS Virus)?
Yes
No
Been admitted to a hospital, seen in an Emergency Department or been advised by a member of the medical profession to enter a hospital for observation, operation or treatment of any kind?
Yes
No
Do you have any pending appointments with any health care provider or medical facility?
Yes
No
Has a biological parent or sibling been diagnosed or treated by a health professional for cancer, heart disease, Huntington's Disease, Lou Gehrig's Disease (ALS), or polycystic kidney disease?
Yes
No
Use or require the use of any mechanical or medical devices such as: a wheelchair, walker, multi-prong cane, hospital bed, dialysis machine, respirator oxygen, motorized cart or stair lift?
Yes
No
Need help, assistance or supervision for: bathing, eating, dressing, toileting, walking, transferring, or maintaining continence?
Yes
No
Is your Mother Still Alive
Yes
No
Please list current age if alive, if passed please list age at death and reason for death.
*
Is your Father Still Alive
Yes
No
Please list current age if alive, if passed please list age at death and reason for death.
*
Back
Next
Authorization and Consent
Please read the attestations below and select a response. Information given is used by JDH Solutions PLLC, for the purposes of assessing eligibility for your quoting, binding, claims, underwriting, investigating, and auditing. Agree to continue application, Disagree if you do not wish to move forward with your application.
I authorize JDH Solutions PLLC to collect and use my personal information for the sole purposes for my personalized insurance quote and binding. All information I have submitted is true and accurate to the best of my knowledge and I have not in any way submitted false, inaccurate, or misleading information on this application or any application submitted on my behave or my company. Any Person Who Knowingly and With Intent to Defraud Any Insurance Company or Another Person Files an Application for Insurance or Statement of Claim Containing Any Materially False Information or Conceals for The Purpose of Misleading Information Concerning Any Fact Material Thereto, Commits A Fraudulent Insurance Act, Which Is a Crime And Subjects The Person To Criminal And [Ny: Substantial) Civil Penal Ties. (Not Applicable in CO, FL, HI, MA, NE, OH, OK, OR VT. In DC, LA, ME, TN, VA and WA Insurance Benefits May Also Be Denied). In Florida, Any Person Who Knowingly and With Intent to Injure, Defraud, Or Deceive Any Insurer Files A Statement of Claim or An Application Containing Any False, Incomplete, Or Misleading Information Is Guilty of a Felony of The Third Degree.
*
Agree
Disagree
Signature
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: