TRANSAMERICA LIFE INSURANCE COMPANY (Final Expense)

TRANSAMERICA LIFE INSURANCE COMPANY

Final Expense
Transamerica Life Final Expense Application

Hassan Sanders
CEO/National Independent Agent
National Producer Number: 12878572

Toll-Free: (855) 468-8900
Direct: (800) 966-4430
Fax: (888) 806-1532

Email: info@DiabeticInsuranceSolutions.com
Website: www.DiabeticInsuranceSolutions.com
PROPOSED PRIMARY INSURED PERSONAL INFORMATION
Full Name of Proposed Insured*

First NameLast Name
Mobile No.*
Email*
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Full Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State of Birth*
Name/Address/of Primary Care Physician:
Primary Care Physician Name*

First NameLast Name
Primary Care Physician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
COVERAGE ELIGIBILITY

I confirm that I have not been diagnosed with, treated for, tested positive for, or been given medical advice by a member of the medical profession for any of the following:
Alzheimer’s Disease or any type of Dementia/organic brain syndrome, cognitive impairment, memory loss, or mental incapacity*

YesNo
Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s disease) or other motor neuron disease*

YesNo
Amputation (other than due to accident/ trauma)*

YesNo
Metastatic, recurrent cancer, or multiple cancers, or cancer (any type other than basal cell of skin) within the last 2 years*

YesNo
Cerebral Palsy; Down Syndrome; Pulmonary Fibrosis*

YesNo
Sickle Cell Anemia; currently bedridden, residing in a nursing home, assisted or long term care facility, or receiving hospice, palliative, or home health care*

YesNo
Eligibility for coverage is not available if any of the above listed conditions apply. Please proceed to the following section only if the box is checked.
PERSONAL HISTORY
Have you received or been advised to seek medical treatment or counseling for the use of, or been advised to discontinue the use of alcohol or drugs, by a member of the medical profession; or joined an organization for dependence or abuse in the past*

0–2 years2–4 years4–10 yearsNone of these
Have you used narcotics, barbiturates, amphetamines, hallucinogens, heroin, opiates, cocaine, or any habit forming drugs except as prescribed by a member of the medical profession in the past*

0–2 years2–4 years4–10 yearsNone of these
Have you been convicted of or pleaded no contest to reckless driving or operating a vehicle while impaired (DWI/OWI/DUI) in the past*

0–2 years2–5 yearsNone of these
Number of these offenses in the past 5 years:
Have you been convicted of or pleaded no contest to a felony or do you have such charge currently pending against you in the past*

0–3 years3–5 years5–10 yearsNone of these
Total number of felonies, convicted or pleaded no contest to in the past 10 years:
Proposed Insured's Height?*
Proposed Insured's Weight?*
Have you ever been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for any of the following: (Select all that apply)*

Heart DiseaseCongestive Heart Failure (CHF)Transient Ischemic Attack (TIA) or Stroke/Cerebrovascular Accident (CVA)Disease or disorder of the kidneys including Polycystic Kidney Disease (PKD) or Neurogenic Bladder (not Kidney Stones unless diagnosed a “Stone Former”)Disease or disorder of the liver or HepatitisDiabetes (other than during pregnancy)Chronic Obstructive Pulmonary Disease (COPD) or any respiratory disorder or disease (excluding allergies or mild Asthma) “Mild” asthma is categorized as: no daily symptoms, no limitations to daily activities, no reduced lung function, no regular use of oral steroids, and no ER visits or hospitalizations due to asthma in the last five yearsCancer or malignancy of any kind (exclude benign or non-melanoma skin cancers or fatty tumors)None of the above
During the last 3 months, have you been on treatment for anemia (lower than normal number of red blood cells)? Include diet, iron pills, iron shots, infusions as treatment.*

YesNo
In the last 12 months, were you a patient in a hospital overnight? (Do not include hospitalization due to child birth without complications or an overnight stay in an emergency room.)*

YesNo
Have you ever been diagnosed by a member of the medical profession or tested positive for any of the following: Acquired Immune Deficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV), and/or tested positive on an AIDS/HIV related test?*

YesNo
Have you ever used nicotine in any form? This includes cigarettes, e-cigarettes/vapes, chewing tobacco/smokeless tobacco, pipe, cigar, nicotine gum/patch, or other nicotine delivery system.*

YesNo
If “Yes,” date of last use:

MonthDayYear
Date
In a typical week, do you perform any intentional physical activity such as yard work, walking, exercising, or playing sports for at least 10 consecutive minutes?*

YesNo
Days:
Is the Owner employed by any cannabis related business?*

YesNo
U.S. CITIZENSHIP
Are you a U.S. citizen?*

YesNo
BENEFICIARIES
Primary Beneficiary*

First NameLast Name
Relationship*
Benefit %*
PRODUCT DETAILS
Rate Class Applied for*

Preferred Non-tobaccoStandard Non-tobaccoPreferred TobaccoStandard TobaccoGraded
If a policy cannot be issued as applied for, would you accept a modified rate class and/or plan?*

YesNo
If Yes, Adjust face amount to premium?

YesNo
Amount Applying For*

$5,000$6,000$7,000$8,000$9,000$10,000$15,000$20,000$25,000$30,000$35,000$40,000
PAYMENT
Initial premium Payment (Type "IMMEDIATELY" below or Pick a Due Date between days 1-28)*
Payor Information (Name As It Appears on Bank Account)*
Type Of Account*

CheckingSavings
Payment Mode*

AnnualMonthly (Checking Account Required)
Signature of Proposed Insured*

Clear
I verify and confirm that my answers to the health questions are try and correct
Please verify that you are human*
Should be Empty: