LIFE APPLICATION:
(Please give detailed responses where necessary)
Proposed Insured Name
*
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Marital Status
Gender
Male
Female
Phone Number
Please enter a valid phone number.
• Drivers' License# and State
*
• Expiration date of driver's license
*
/
Month
/
Day
Year
Date
• Height on driver's license
*
• Weight on driver's license
*
• Mailing address if different from residence address
*
• Country of birth/city and state
*
• Amount of Life insurance applying for with Farmers
*
What Type of Life Insurance are you interested in?
Term (10/20/30 years)
IUL (Indexed Universal Life)
Please call me to discuss what best fits my needs
• How long with your employer
*
• Duties with occupation
*
• Bankruptcies, levies, liens, foreclosures, repos, etc.
*
• Life companies, policy numbers, and death benefits
*
• Ever had any Life insurance declined, rated, modified,
*
• Purpose for this Life insurance income replacement,
*
• Will billing/payment be monthly electronic funds
*
• Primary beneficiaries and contingent beneficiaries need
*
• Primary and other physician's names, addresses, contact numbers, last visit and reason
Any medications: (dosage/frequency, etc and for what condition)
• Been hospitalized last 2 years for more than 5 days for
*
• Past 90 days been unable to perform duties at work
*
• Past 5 years pied guilty or had any convictions
*
pied guilty or convicted for reckless driving or DUI/DWI
*
• Next 2 years plan to travel or work outside U.S.
*
member of a flight crew or participate in hang gliding, para sailing, jumping, rock or mountain climbing, organized racing of auto, motorcycle, boat, snowmobile, etc. or underwater diving, parachuting, skydiving...
*
deafness, missing limbs, heart defect, Down's Syndrome,
*
Past 5 years consulted with, been diagnosed or treated by a member of the medical profession or hospitalized or taken medication for: Please provide details for any answer other than "NO
• Chest pain, angina, heart attack, heart murmur, stroke, irregular heartbeat, heart disease or coronary artery
*
lymphoma, colon polyp or any malignant or benign
*
diabetes, anemia, blood or thyroid disorder or pituitary or
*
hepatitis, ulcers, intestinal bleeding, cirrhosis or weight
*
traumatic stress, attention deficit, hyperactivity, bipolar or
*
asthma, pulmonary disease, emphysema, chronic bronchitis, sleep apnea or any other disease or disorder of the lungs
*
• Kidney, bladder, urinary, reproductive organ or prostate disorder
*
• Arthritis, fibromyalgia, gout, back or joint pain, muscle
*
Have you ever used or been treated for the use of amphetamines, barbituates, cocaine, marijuana, opiates, illegal drugs
*
• Have you ever been advised by a medical professional to reduce or stop drinking alcohol or received treatment of any kind for alcohol use.
*
• Do you currently drink alcohol / how many drinks per day
*
In the past 5 years, have you been disabled, received disability income/benefits or been unable to work for any other reason (besides maternity leave or minor surgery)
*
In the past 5 years have you been diagnosed by a member of the medical profession for any other illness, disease, or injury not included in the preceding questions
*
FAMILY HISTORY
• Both parents living ages (if no, provide year of loss and medical cause of death)
*
• How many siblings living and ages (if no, provide year and medical cause of death)
*
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