Ballentine Insurance Agency Life Application

Primary Beneficiary

Who do you want the proceeds to go to if you were to pass away? **Spouse if married | Parent, child, family member, etc if not married
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SSN*
Date of birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Tobacco/Nicotine Use:*

Never used any nicotine product or stopped more that a year ago.Currently use tobacco products.
Parent 1*

LivingDeceased
Cause of death? If so at what age?
Type N/A if still living
Parent 2*

LivingDeceased
Cause of death? If so at what age?
Type N/A if still living
Number of siblings*
Health Status of each

IN ORDER TO START THE POLICY, WE WILL NEED BANK NAME, ROUTING AND ACCOUNT NUMBER. YOU CAN CALL THE OFFICE TO PROVIDE THIS INFO IF YOU WISH.
Billing Draft day
Bank Name
Account Number
Routing Number
Do we have your permission do draft the first premium?

YesNo
Would you like to accept temporary insurance while your application is being processed?

YesNo
Should be Empty:

Primary Beneficiary