Accuracy Is Our Goal - Life Policies

1

Provide your legal nameThe name you will use when submitting your official application for coverage.

Prefix

First Name

Middle Name

Last Name

Suffix

2

Enter your current ageEx: 28

3

What is date of birth?* This field is required.Format (mm/dd/yyyy)

4

What do you do for work?

5

Are you married?

YESNO

6

Are you a parent?Include their names and ages.

Put n/a if this does not apply

7

Do you have any grandkids? Include their names and ages.

Put n/a if this does not apply

8

Do you regularly participate in dangerous hobbies?i.e: skydiving

9

What is the total amount of your monthly take home pay?

10

What is the ideal amount you prefer to spend each month for your policy? What is the max?Please note a policy can be paid monthly, quarterly, and every six months.

Indicate if you prefer quarterly or six months

11

Are you a homeowner?

YESNO

12

How much does it cost you per month to ensure a roof over your head?List the monthly amount of your rent or mortgage.

If you have both rent & mortgage- please add

13

Renters: How much do you pay yearly at your current home?

Homeowners put in n/a

14

Homeowners: How much is left of your mortgage

Renters put n/a

15

Do you have anyone reliant on your income?This only applies if your income helps their day to day livelihood.

YESNO

16

Do you rely on anyone else's income?This only applies if their income affects your day to day life.

YESNO

17

What made you start looking into coverage?

18

How much coverage were you shopping for?If you aren’t sure - no worries! Type what amount you think you will need.

19

Do you have any other life insurance policies?Do NOT include any work life insurance policies.

20

Ideally, how long would you like your coverage to last for?There are no right or wrong answers to this question.

21

Do you consume nicotine products? If yes - have you been diagnosed with COPD?

22

Are you currently wearing stents to prevent blood clots?

23

Have you been prescribed an inhaler?Make sure to include the name of the inhaler

If you can’t remember the name, that is fine.

24

Have you ever had cancer, a heart attack, or a stroke?If you’ve had more than one, please indicate how many.

25

Do you take any medication that is designed to treat chronic pain?i.e: Gabapentin, Oxycodone, Hydrocodone

26

Do you have type 2 diabetes? What was your lastest AC1 level?

If you do not have diabetes, put in/a

27

Are you taking insulin?

YESNO

28

How many milligrams of metformin do you take?

29

Have you been diagnosed with anxiety or depression?

YESNO

30

Have you been hospitalized for mental health reasons?If it’s been more than seven years answer no.

YESNO

31

Have you been a patient of a drug rehab facility?If it’s been more than seven years answer no

YESNO

32

Have you been diagnosed with high blood pressure?

33

Have you had any surgeries in the last couple of years?

YESNO

34

Please provide your height and weight

35

If you have been prescribed any other medications that were not listed above provide them below

36

Have you been convicted of a felony within the past seven years?

YESNO

37

Do you have any felony charges pending at the moment?

YESNO

38

Have you had three or more speeding tickets in the last few years?

YESNO

39

Signature Required* This field is required.Signing this form confirms that you agree that all questions have been answered to the best of your abilities and knowledge.