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Life Application Form
How did you hear about us?
*
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Google
Facebook
Other Social Media
A Customer Referred Me
Newspaper Ad
Saw Your Sign
Met An Agent At An Event
My Mortgage Lender Referred Me
My Realtor Referred Me
Are you already working with a team member at Schultze Agency? If so, select one:
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Jeff Schultze
Jaime Schultze
Nicolle Borton-Cobuccio
Not working with anyone
Proposed Insured
Legal Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Marital Status
Please Select
Married
Single
Divorced
Gender
*
Please Select
Male
Female
Place of Birth (City & State)
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Email
*
example@example.com
SSN
*
Height
*
Weight
*
Phone Number
*
Please enter a valid phone number.
Do we have permission to communicate via text with you at this number?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Will the Proposed Insured be the Owner?
Yes
No
Will there be a policy Co-Owner?
Yes
No
Proposed Insured/Owner Continued
If juvenile is the insured the information applies to the owner of the policy.
U.S. Driver's License #
*
State of Issue
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Expiration Date
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/
Month
/
Day
Year
Date
Are you a U.S. Citizen?
*
Please Select
Yes
No
Name of Current Employer
*
Length of Employment W/Company
*
Address of current employer
Yearly Income (Gross)
*
Combined Household Income
Total life insurance coverage in force or currently applied for on spouse/domestic partner/civil union partner
Please enter $0 if no Spouse/Domestic/Civic Union
Proposed Policy Co-Owner
Only applies if there is a policy Co-Owner
What is your relationship to the primary proposed insured?
Name and SSN
Gender
Male
Female
Residential Address
(if different from the primary proposed insured)
Beneficiary Information
Please list the names of the Beneficiary(ies) you would like AND Their Date of Birth, AND the relationship to the primary proposed insured, and percentage of benefit. Example: Jon Doe , 12/10/83 ,spouse, 50% death benefit
If there are multiple beneficies, please note percentages that go to each. Must add up to 100%
Contigent Beneficiary Information
Applies ONLY if you want to have a contigent beneficiary. A contigent beneficiary is a person to receive death benefit if the if the primary beneficary is not alive a the time of the insured's death.
Please list the names of the contigent Beneficiary(ies) you would like AND Their Date of Birth, AND the relationship to the primary proposed insured, and percentage of benefit. Example: Jon Doe , 12/10/83 ,spouse, 50% death benefit
If there are multiple beneficies, please note percentages that go to each. Must add up to 100%
Coverage Information
What is the purpose for this life insurance?
Financial Details
Have you filed for Bankruptcy in the past seven years?
*
Please Select
Yes
No
Is this a business-related sale?
*
Please Select
Yes
No
Is any Proposed Insured less than 15 days or more than 70 years of age as of the date of the Application?
Yes
No
Temporary Insurance Agreement Application
Eligibility RequirementsThe Primary Proposed Insured in the Application must answer the questions set forth below.In order to qualify for temporary insurance:1. The Proposed Insured must have completed and signed the Application;2. the Proposed Insured or Proposed Policy Owner(s), if different from the Proposed Insured(s), must have paid the first full modal premium; and3. the Proposed Insured must truthfully answer the following five questions “No.” If any of the following five questions cannot be truthfully answered “No” by the Proposed Insured or if any of the five questions are left blank, no agent of FNWL is authorized to collect premiums associated with the Application and neither temporary insurance nor life insurance coverage is in force by virtue of the Application or this TIAA for the Proposed Insured
Has the Proposed Insured(s) ever been told by a member of the medical profession that he/she had, or consulted a physician for, or received medical treatment for any of the following: disorder of the heart or blood vessels, angina, heart attack, stroke, cancer, tumor, Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or any other immunological disorder, drug dependency, or alcohol dependency?
Yes
No
Within the past two years, has the Proposed Insured(s) been hospitalized for more than five days for any reason?
Yes
No
Has the Proposed Insured(s) ever applied for life insurance which has been declined, rated or modified in any way?
Yes
No
Within the past 90 days has the Proposed Insured(s) been unable to perform the normal duties of his/her occupation for 15 or more working days because of illness or injury? BackNext
Yes
No
Payment Information
Billing Method
EFT monthly
Annually
EFT Payment INFO
Banking Instituition Name
9 digit ROUTING number
Account Number
Premium Allocation/Communciations (UIL only)
Telephone transfers
Yes. By checking YES, "I (we) as Policy Owner(s), authorize Farmers New World Life Insurance Company to act upon my telephone transfer request. I understand and agree that telephone transfers will be subject to conditions of the policy
No. I(we, as Policy Owner(s), do not authorize telephone transfers.
Are you ok with Electronic Delivery Election?
Yes. By checking YES, "I (we) as Policy Owner(s), authorize FNWL to provide my annual reports by electronic delivery. I understand that I must have access to a personal computer with appropriate computer hardware/software. I may request paper copies of the annual reports at any time.
No. You will recieve these documents via the U.S. mail
Existing Insurance Information
is there any life insurance policy or annuity contract in force or application pending on the life of the Proposed Insured, including policies sold or assigned to a trust or viatical/life settlement company?
Yes
No
If YES, provide the following: Life Company name, amount of life, owner.
Will you be replacing this policy?
Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract?
Primary Physician Information
Do you have a primary health care physician?*
*
Please Select
Yes
No
If Yes what is their name, address and phone number?
What was the date of your last visit?
Reason for Last Visit
HIV - Application State
Notice and Consent for Blood and/or Bodily Fluid TestingFNWL may request that you provide a sample of your blood and/or bodily fluid to test for the presence of Human Immunodeficiency Virus (HIV). The Notice and Consent for HIV Testing form provided with this Application contains information regarding HIV testing, consent, disclosure and notification of test results.Please designate to whom you wish the results to be released, which may include positive or abnormal HIV, Hepatitis B and/or Hepatitis C results.I authorize the release of my test results, which may include positive or abnormal HIV, Hepatitis B and/or Hepatitis C results, to my Physician, Health Care Provider or Health Care Agency:Note: If the test indicates a positive test result, but you do not designate a private physician, the test results will be provided to you by a representative of the Texas Department of Health.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Personal History
Have you, in the past five years, used Tobacco or Nicotine products in any form (e.g. cigarettes, pipes,cigars, snuff, chewing tobacco or nicotine delivery device such as gum or patch, etc.)?
*
Please Select
Yes
No
If YES, Type of Tobacco or Nicotine product(s) and Date(s) Last Used
Have you, in the past ten years, had your driver's license suspended, revoked, pled guilty to, or beenconvicted of reckless driving, or driving under the influence (DUI/DWI)?
*
Please Select
Yes
No
If YES, type of violation(s)
Pled guilty to or convicted of reckless driving
Driving under the influence (DUI/DWI)
Revoked
Suspended
Have you, in the past five years, pled guilty to or had any other driving conviction(s) (e.g. speeding, cellphone/texting, accident, etc.)?
*
Please Select
Yes
No
If YES, Number of Driving convictions? How long ago was your most recent driving conviction?
Have you, in the past ten years, pled guilty to or been convicted of a felony or misdemeanor, or are such charges pending against you, or are you currently on parole or probation?
*
Please Select
Yes
No
If YES, type of felony(ies)/misdemeanor(s), location(s) (city,state), date(s).
Have you had an application for life, accident, or health insurance, or reinstatement of a policy, declined,postponed, cancelled, or issued other than as applied for?
*
Please Select
Yes
No
If YES,Type(s) of insurance: (life, accident, health), reason(s), date9s)
Are you a member of the military, military reserve or National Guard (active or inactive) or do you have awritten agreement to become a member at the future date?
*
Please Select
Yes
No
If YES, Current Duties, Current assignment location
If YES,Have you been alerted or received orders for duty outside the U.S.? Are you currently receiving, or within the next 2 years do you expect to receive, hazardous duty or incentive pay?
Have you, in the past two years, flown as a student pilot, pilot or crew member (or do you plan to within the next two years)?
*
Please Select
Yes
No
Within 2 years
Within the next two years, do you plan to travel outside the US? If YES, where and for how long?
Have you, in the past two years, or do you plan to in the next two years, take part in hang gliding, parasailing, para kiting, parachuting, skydiving, ultralight, soaring, ballooning, bungee jumping, rock or mountain climbing, organized racing by automobile, motorcycle, powerboat or snowmobile, or underwater diving?*
*
Please Select
Yes
No
Future
Medical History
Have you lost more than 15 pounds over the past 12 months?
*
Please Select
Yes
No
If YES, what was the weight loss do to? How many pounds did you lose in 12 months?
Do you have any congenial or birth disorders including blindness, deafness, missing limb(s), heart defect,Down's Syndrome, Autism or any other congenital disorder?
*
Please Select
Yes
No
If YES, which disorder?
Have you, in the past five years, been treated for, been hospitalized for, or been diagnosed by a member of the medical profession as having Human Immunodeficiency Virus (HIV) antibodies or antigens or AcquiredImmune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC) or any other immune deficiency disorder, or have you tested positive for HIV antibodies or antigens?
*
Please Select
Yes
No
Have you ever used or been treated for the use amphetamines, barbiturates, cocaine, marijuana, opiates, hallucinogens or any other illegal drugs or have you been treated by or consulted a member of the medical profession for abuse of prescription drugs?
*
Please Select
Yes
No
Have you ever been advised by a medical profession to reduce or stop drinking alcohol, or received treatment of any kind for the use of alcohol?
*
Please Select
Yes
No
Do you currently drink alcoholic beverages?
*
Please Select
Yes
No
Have you, in the past five years, been disabled, received disability income benefits, or been unable to to work or perform and carry out your normal daily functions for any reason other than maternity leave or recovery from minor surgery?
*
Please Select
Yes
No
Have you, in the past five years, been diagnosed by a member of the medical profession for any other illness, disease, or injury, not included in your answers to any of the preceding questions?
*
Please Select
Yes
No
Have you, in the past five years, been admitted or advised to be admitted to any hospital or health care facility; or undergone or been advices to have surgery, biopsies, treatment or medical test that are not included in your answers to any of the preceding questions?
*
Please Select
Yes
No
Have you ever attempted suicide?
*
Please Select
Yes
No
Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication for High Blood Pressure or high cholesterol/ hyperlipidemia?
*
Please Select
Yes
No
Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication for Chest pain, angina, heartattack, heart murmur, stroke or transientischemic attack/ministroke (TIA), irregularheart beat/rhythm, othercirculatory or heartdisorder or coronaryartery/heartdisease/atherosclerosis?
*
Please Select
Yes
No
Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication for Cancer, tumor, mass, skin cancer includingmelanoma, leukemia, lymphoma, colon polyp, or any malignant orbenign growth?
*
Please Select
Yes
No
Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication for Diabetes, impaired glucose tolerance (pre-diabetes), gestational diabetes, anemia or other blood disorder(excluding HIV), or disease or disorder of the thyroid, pituitary or adrenal glands?
*
Please Select
Yes
No
Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication for Disorder of the liver, pancreas, digestive system or spleen including hepatitis, ulcers, intestinal bleeding, cirrhosis, fatty liver, or weight loss surgery?
*
Please Select
Yes
No
Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication for Depression, anxiety, stress, eating disorder(anorexia or bulimia), post-traumatic stress, attention deficit/attention deficit hyperactivity, bipolar or other psychiatric or mental health disorder?
*
Please Select
Yes
No
Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication for Seizures, paralysis, multiple sclerosis, memory loss or other disease or disorder of the nervous system
*
Please Select
Yes
No
Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication Asthma, chronic obstructive pulmonary disease, emphysema, chronic bronchitis, sleep apnea or any other disease or disorder o fthe lungs or respiratory system
*
Please Select
Yes
No
Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication for Kidney, bladder, urinary, reproductive organ(other than contraceptive medication) or prostate disorder
*
Please Select
Yes
No
Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication for Arthritis, fibromyalgia, gout, back or joint pain or muscle disorder, orLupus
*
Please Select
Yes
No
If you answered YES to ANY of these questions, please provide more details such as condition , when diagnosed, medications, doctor info, etc
List any and all medications (include the name, dosage, frequency, how long you were on the medication and it's purpose):
Family History
Please only list biological parent information, if known, otherwise select “Unknown” from the Status dropdown.
Family History Parent 1
*
Please Select
Living
Deceased
Current age at death?
Cause of death
Medical Conditions
Age at Diagnosis
Family History Parent 2
*
Please Select
Living
Deceased
Current age at death?
Cause of death
Medical Conditions
Age at Diagnosis
Family History: How many siblings? Are they living or deceased and any known medical conditions? Please list all below. Note if deceased please list cause of death and age at death.
What agent did you speak to about life coverage?
*
If you had an ideal budget to pay for life insurance, what would your monthly budget be?
$100/month
$200/month
$300/month
$400/month
Any additional notes you would like us to know?
Submit
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