Application

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Policy Application

Please fill all required information marked with a red *. For your safety, this form is encrypted and secure 🔒 🔰 The applicant is the person applying for coverage. The owner is the person paying for the policy. Sometimes they are the same person. Sometimes they are not if you are the applicant and the owner just fill out the applicant portion. If at anytime you have questions about how to fill out this form please contact us.
Applicants Full Legal Name*

First NameLast Name
Middle name or initial?
Suffix?
Any Jr? The 1, 2, 3?
Applicants Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicants Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Applicants Email*
example@example.com
Applicants Date of birth*
What type of coverage are you applying for?*

Whole life aka final expenseIndex universal life (IUL)Living TrustTerm lifeAnnuityLong term care policy
Amount of coverage ?
What is the applicants drivers license number and state?*
What is the applicants social security number?*
What state OR country were they born in?*
Policy owner information

A person can apply for a policy for another person . For example, a mother can apply for her child . In that case, the mother would be the owner and the child would be the applicant. Because of this, please answer the questions below ⚠️ Please select “yes” or “no” below ⚠️ If “NO” you must complete this section ⚠️If “YES” please skip this section and go to the next section labeled “HEALTH INFORMATION”
Is the owner and the applicant for this policy, the same person ?*

YesNo
Policy Owners Name

First NameLast Name
Policy Owners Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Owners Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Policy Owners Email
example@example.com
Policy owners date of birth

MonthDayYear
Policy owner is the person who own the policy not the applicant or insurer themselves
Policy owner social security number
Policy owner is who pays for the policy of not the applicant / insured
Policy owners drivers license number and state
Policy owners State or County of birth
Please provide owners relationship to the applicant / proposed insured and any other information you may find important regarding the relationship between the owner and the applicant
Do you want policy information mailed to the owner and the applicant?

Yes, mail to the owner and the applicantNo, only mail to the ownerNo, only mail to the applicantThe owner and the applicant are the same
Health Information 🩺

Information about the applicant
What is your doctors name?*
Doctors Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctors Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of last visit?*

MonthDayYear
OK to estimate
Reason for visit?*
What is your weight?*
What is your height?*
Are you taking, or have you taken, any medications in the past 10 years?*
Please list them above 👆🏻
If yes, please provide for which medical conditions?
Include any diagnosis
For any chronic/ ongoing medical conditions please provide your most current readings/status 🩺
Diabetic A1c / blood pressure average / blood sugar levels/ cancer stages or remission status as examples of needed information ℹ️
Have you had any medical complications within the past 10 years? Any complications regarding your kidneys, heart, lungs, skin urinary tract, eyes bones, or any infectious diseases?
If anything was ever reported to a doctor, it will be traceable through your medical information search it is better to tell the truth first. We have options for people with all health concerns.
Are you awaiting any results for diagnostic test?
Is so please list what test and when you expect the results?
Are you currently physically active?*
Do you clean your home, exercise, do yard work, or spend time outdoors?
How many days a week are you active?*
Do you use illicit substances, such as THC, cannabis, cocaine, heroine, pcp, mdma, fentanyl, ecstasy or any other non prescription drugs?*

Yes I use illicit substances regularlyYes I use but cannabis products onlyNo I no longer use illicit substancesNo I have never used any illicit substances
Do you or have you used nicotine or tobacco?*

Yes I use nicotine or tobaccoYes I have but I do not currently use nicotine or tobaccoYes I have but I am currently quittingNo I have not ever used nicotine or tobacco
Do you drink alcohol?*

Yes, regularlyYes, sociallyYes, on occasionNo
Have you ever been advised by a doctor to stop the use of alcohol, substances , or nicotine?

Yes alcoholYes substancesYes nicotineNo
Are you currently in an assisted living, nursing home, or receiving care for your daily routine?

Yes I am in a nursing homeYes I am in assisted livingYes I receive careNo
Personal and Employment History

For applicant
Do you plan to travel outside the US?

Yes within the yearYes after the yearYes not sure whenNo
Does the applicant have any arrest, bankruptcies, issues with law enforcement or judicial systems?
Please list any legal concerns for the past 10 years
Do you have any dangerous hobbies or have a dangerous job?
This includes racing, scuba, diving, flying planes, bungee jumping, working with wild animals, etc…
What is the applicants employment status?*
What is the name of applicants employer?*
How much does the applicant make annually?*
Okay to estimate gross
What type of work does the applicant do?*
What is your job title?
What is the applicants net worth?*
Okay to estimate
What is the applicants household annual income?*
Okay to estimate you and your partners combined annual income
What is the applicants relationship status?*
Beneficiary information
Beneficiaries Name*

First NameLast Name
Does your beneficiary have the same address as you?*
If no, please fill out the beneficiaries address below
Beneficiaries Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Beneficiaries Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Beneficiaries Email
example@example.com
Beneficiaries social security number
Beneficiaries date of birth*
What is their relationship to the applicant?*
What percentage of benefit will they receive?*
All benefits must add to 100%
Do you/they have more than one beneficiary?
Contingent beneficiary is someone who would take your beneficiaries place if something was to happen to them. IT IS NOT REQUIRED.
Name any other beneficiaries and the information you have to provide for them, including the amount you wish them to inherit here:
Are they your contingent beneficiary?*
Contingent ONLY receives benefits if your first beneficiary is no longer alive, or able to receive the benefits.
Family History
Do you have any siblings? If so what are their ages and do they have any health concerns?*
Is your father alive?*

YesNoUnknown
What is his current age or age of death?
Does he have any health concerns, or did he pass from health related issues?
Please say yes or no and describe if yes
Is your mother alive?*

YesNoUnknown
What is her age or age of death?
Does she have any health concerns, or did she pass away from health related issues?
Please say yes or no and describe if yes
Do you have any siblings?*

YesNoUnknown
What are the ages of your siblings and do they have any health concerns?
Premium options

How and when you would your insurance premiums drafted?
How often would you like to draft to your premiums?*
Is there a specific day you would like to start drafting your premiums?*
If yes which day?
You can chose to have your payments come out the same day every month like "on the 15 of the month" Or even the same frequency like, "the third Tuesday if the month"
Are you providing a lump sum premium?

YesNoI am using a 1035 exchange for my IRA or 401k
If yes what is the amount of the lump sum premium or exchange amount?
Please provide where will the premiums come from

This information is *REQUIRED*. It will be kept safe and secured and will also be used to confirm your identity 🏦
𝐍𝐚𝐦𝐞 𝐨𝐧 𝐀𝐜𝐜𝐨𝐮𝐧𝐭*
𝐑𝐨𝐮𝐭𝐢𝐧𝐠 𝐍𝐮𝐦𝐛𝐞𝐫*
𝐀𝐜𝐜𝐨𝐮𝐧𝐭 𝐍𝐮𝐦𝐛𝐞𝐫*
𝐅𝐢𝐧𝐚𝐧𝐜𝐢𝐚𝐥 𝐈𝐧𝐬𝐭𝐢𝐭𝐮𝐭𝐢𝐨𝐧 𝐍𝐚𝐦𝐞 *
How would you like to receive policy information? Chose all that apply

Mail to ownerMail to applicantEmail to ownerEmail to applicantEmail & mail to ownerEmail & mail to application
Signature*
Thank you!

Your application will now be reviewed and processed by Chelsea George. We will use all of our resources with the information above to secure you the highest amount of coverage possible to you. Please review, and double check all of your information for any errors and click continue when finished ✅
I reviewed my application and everything is correct*

YesNo
Should be Empty:

Policy Application

Policy owner information

Health Information 🩺

Personal and Employment History

Beneficiary information

Family History

Premium options

Please provide where will the premiums come from

Thank you!