Life Insurance Application:
You have a family member who wants to bless you you/their Grandchild with an Infinite Banking Policy. "THE INSURED" would be you/your child, which may be of any age. You will also see information gathered on "THE PARENT". Please fully and accurately provide all of the requested information below to help us submit this application and receive an official underwriting approval. Any quotes or illustrations that have been seen so far are pending underwriting approval. It is possible you may be contacted for a few follow up questions from underwriting after answering everything on this form. By submitting this form you are consenting for us to file this information for the electronic application. Even if your submitted application is approved by underwriting, all parties have no obligation to accept the approved coverage and can simply decline it at any time. Thank you for your time and prompt attention, so we can proceed with the process and establish this wealth blessing! (note: you should be able to save and continue where you left off) Again, thank you for your prompt reply.
INSURED'S INFORMATION
IF THERE ARE MULTIPLE INSURED THAT ARE BEING APPLIED FOR, PLEASE BE SURE TO FILL THIS SECTION OF THE FORM OUT ON EACH INSURED, WITH A NEW JOT FORM.
Insured's Name
*
First Name
Last Name
Insured's Date of Birth
*
Insured's Sex
*
Male
Female
Insured's Marital Status
*
Married
Single
Divorced
Widowed
Is insured active duty military?
*
Yes
No
Insured Driver's License State of Issue or enter N/A
*
Insured Driver's License Number or enter N/A
*
Insured Driver's License Expiration Date or enter N/A
*
Insured's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many years has the insured lived at this address?
*
Insured's Phone Number or N/A
*
Please enter a valid phone number.
Format: (000) 000-0000.
Insured's Social Security Number
*
What city and state was the insured born in? (City, State)
*
Insured Employer's Name (if unemployed, just type unemployed)
*
Insured's Job Title (if unemployed, just type unemployed)
*
How many years has the insured worked there? or type N/A
*
What is the name, address, and approximate date of last visit for the insured's primary care physician?
*
List any and all medical conditions the insured has been diagnosed with in the past 5 years. Please provide as many details if possible including when the insured was first diagnosed, the doctor treating them, and the date of the last doctor's visit. If none, just type none.
*
Please list all medications insured is currently taking. What is the prescription name, dosage, how long have they been taking it, and who is the doctor who prescribed it? If none, just type none
*
Insured's Height
*
Insured's Weight
*
Is the insured's father still alive?
*
Yes
No
What is the age of the insured's father? If deceased, please list the age he died at, and the cause of death
*
Is the insured's mother still alive?
*
Yes
No
What is the age of the insured's mother? If deceased, please list the age she died at, and the cause of death
*
Is the insured's brother/s still alive?
*
Yes
No
N/A
What is the age of the insured's brother/s? If deceased, please list the age he died at, and the cause of death or N/A
*
Is the insured's sister/s still alive?
*
Yes
No
N/A
What is the age of the insured's sister/s? If deceased, please list the age she died at, and the cause of death or N/A
*
Does the insured use tobacco?
*
Yes
No
PRIMARY PARENT INFORMATION
IF YOU ARE FILLING THIS FORM OUT FOR MULTIPLE INSURED/CHILDREN - BE SURE TO FULLY COMPLETE THE FIRST CHILD'S FORM IN ENTIRETY. When filling out the second, third,... form for more children, BE SURE THE 1ST HALF TITLED "INSURED" SECTION OF THE FORM, HAS BEEN FULLY COMPLETED. For the next child, you can input again or put N/A in the blanks in the PRIMARY PARENT SECTION to save time)
Primary Parent Name
*
First Name
Last Name
Parent Sex
*
Male
Female
Parent Date of Birth
*
What state was the Parent born in?
*
What is Parent's Social Security Number?
*
What is Parent's License Number?
*
Parent's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many years has the Parent lived at this address?
*
What is Parent's Phone Number?
*
Insured's Email or N/A
*
example@example.com
Parent's Email
*
example@example.com
Insured's Approximate Annual Income or N/A
*
Insured's Approximate Net Worth or N/A
*
Parent's Approximate Annual Income
*
Parent's Approximate Net Worth
*
Parent's Approximate Value of Retirement Accounts (401k/s, IRA's, Roth IRA's, etc)
*
How much are Parent's health insurance premiums (If no coverage, just type $0)
*
Signature of person filling out this form, consenting to submit your electronic application on your behalf.
*
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