Burleson Insurance Agency
210 S Walcott St, Jefferson, TX, 75657 - (903) 665-8048
LIFE INSURANCE APPLICATION
PROPOSED INSURED INFORMATION
Name
*
First Name
Last Name
MIDDLE Name (optional)
Date of Birth
*
/
Month
/
Day
Year
Gender at Birth
*
Male
Female
Height (Feet)
*
Please Select
0
1
2
3
4
5
6
7
8
Height (Inches)
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
11
Weight (lbs.)
*
Weight in Pounds
Country of Birth
*
Please Select
USA
Other
State of Birth
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Country of Birth (Please Specify)
*
Specify Country if other than USA
Are you a United States Citizen?
*
Yes
No
If "No", are you residing here legally with a Temporary (Non-immigrant) Visa or Permanent Resident Visa (Green Card)?
*
Yes
No
If "Yes", provide Visa Type.
*
Please Select
E - Treaty Traders/Investors
G - Intl Org/Foreign Gov Personnel
H-1 - Temp Workers w/ Spec Merit/Ability
H-4 - Dependents of H-1 Visa Holder
I - Information Media Representative
K - Family/Fiance' of U.S. Citizen
L - Intra-company Transfer
N - Family Member of G Visa Holder
O - Workers with Extraordinary Ability
P - Entertainer/Athlete
R - Ministers/Religious Workers
TN - Canadian and Mexican Pros - NAFTA
TD - Dependents of TN Visa Holders
Greencard/Permanent Resident Visa
Other
Other Visa Type Details
*
Visa Expiration Date
*
/
Month
/
Day
Year
How many years have you continuously resided in the U.S.?
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number (cell phone recommended)
*
Please enter a valid phone number.
Does the Proposed Insured have a Driver's License?
*
Yes
No
U.S Driver's License #
*
DL State of Issue
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Type of ID other than DL
*
Please Select
Passport
U.S. Military ID
Permanent Resident Card
Other
ID #
*
Country of Issue (Please Specify)
*
Specify Country if other than USA
DL Expiration Date
-
Month
-
Day
Year
Date
Social Security Number - (SSN is required to apply for, and acquire, any life insurance policy)
*
What is the applicant's EMPLOYMENT status?
*
Please Select
Employed (including Self-Employed)
Not Employed
Retired
Student
Homemaker
Juvenile
Disabled
Employer Name
*
Occupational Title
*
Job Duties
*
Number of Years with Current Employer/Company
*
Annual Earned Income
*
Include income from all income/ revenue sources.
Total amount of Life Insurance Coverage in force or applied for on Spouse/Domestic Partner
*
As Policy Owner, you have the right to designate another person to receive correspondence. Would you like to designate a third party to receive such notification?
*
Yes
No
**IF YES, please provide their Name and Mailing Address
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BENEFICIARY INFORMATION
PRIMARY Beneficiary Name (The Primary Beneficiary is the person who would receive the life insurance payout. The Primary Beneficiary can be changed later if desired)
*
First Name
Last Name
Relationship to Primary Proposed Insured
*
Please Select
Child
Estate of Insured
Ex Spouse
Fiancee
Grandchild
Grandparent
Parent
Sibling
Spouse/Domestic Partner
Step Child
Step Parent
Primary Beneficiary Date of Birth, Phone Number, & Address (if available)
Would you like to list a Contingent/Secondary Beneficiary at this time? (If the Primary Beneficiary above either died before you, or died at the same time as the applicant, the life insurance payout would be paid to the contintent beneficiary. A contingent beneficiary can be added or changed later if desired)
*
Yes
No
Contingent/Secondary Beneficiary Name
*
First Name
Last Name
Contingent Relationship to Primary Proposed Insured
*
Please Select
Child
Estate of Insured
Ex Spouse
Fiancee
Grandchild
Grandparent
Parent
Sibling
Spouse/Domestic Partner
Step Child
Step Parent
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REQUESTED LIFE COVERAGE
Requested Life Policy TYPE (the type can possibly be changed before policy submission/start of the policy)
*
Please Select
Term Life
Whole Life
Universal Life
Requested Life Coverage AMOUNT (the amount can possibly be changed before policy submission/start of the policy)
*
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FINANCIAL DETAILS
Have you Filed for Bankruptcy in the past 7 years?
*
Yes
No
If "Yes" - Type of Bankruptcy
*
Date Filed (Month and Year)
*
Has the bankruptcy been discharged?
*
Yes
No
Date Discharged (Month and Year)
*
TEMPORARY INSURANCE ELIGIBILITY
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, have you 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 have you been unable to perform the normal duties of your occupation for 15 or more working days because of illness or injury?
*
Yes
No
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" - What is the current Life Insurance Company Name?
*
If "Yes" - Amount of current Life Insurance coverage?
*
Do you plan on replacing your current life policy if/when this life application is approved? Or do you plan on leaving this current policy in force and ADDING a life policy with this application?
*
Replacing current policy
Not replacing current policy and leaving it active
Do you plan on, or are you considering, any of the following: reducing, discontinuing or stop making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract if/when the life insurance policy applied for is issued?
*
Yes
No
Are you (or the applicant of this life application) the Owner of the current life policy already in force?
*
Yes
No
If "No" - List the owner's name of the current life policy in force
*
What is the TYPE of Life Policy that is currently active and in force? (if known) (check all that apply)
Term Life
Whole Life
Universal Life
Policy Number of current active life policy (if known / optional)
Year current active life policy was issued (if known / optional)
PRIMARY PHYSICIAN INFORMATION
Do you have a Primary Care Physician? (Do you have a normal "go-to" doctor?)
*
Yes
No
If "Yes" - Primary Care Physician/Health Care Provider Name
*
First Name
Last Name
Primary Care Physician - STREET Address:
Primary Care Physician - CITY:
*
Primary Care Physician - STATE:
*
Primary Care Physician - Zip Code:
Primary Care Physician/Health Care Provider Phone Number
Please enter a valid phone number.
Reason for Last Visit
*
MONTH and YEAR of Last Visit (MM/YYYY)
*
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PERSONAL HISTORY
Have you, in the past 5 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)?
*
Yes
No
If "Yes" - What TYPE of Tobacco or Nicotine product? (select all that apply)
*
Chewing Tobacco
Cigar
Cigarette
Nicotine Gum/Patch
Pipe
Snuff
DATE of Last Use (of EACH Tobacco or Nicotine product selected above) (MM/YYYY)
*
Have you, in the past 10 years, had your driver’s license suspended, revoked, pled guilty to, or been convicted of reckless driving, or driving under the influence (DUI/DWI)?
*
Yes
No
If "Yes" - Select the Type of Violation(s) (Select all that apply)
*
Pled guilty to or convicted of reckless driving
Driving under the influence (DUI/DWI)
Revoked
Suspended
Indicate Conviction Timeframe of any/each of the viloations selected above
*
Within previous 2 years
3 to 5 years ago
5 to 10 years ago
Have you, in the past 5 years, pled guilty to or had any other driving conviction(s) (e.g. speeding, cell phone/texting, accident, etc)?
*
Yes
No
If "Yes" - Select number of driving convictions:
*
1 or 2
More than 2
Most recent driving confiction was:
*
Within previous 2 years
3 to 4 years ago
Over 4 years ago
Have you, in the past 10 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?
*
Yes
No
If "Yes" - List the Type of Felony(ies) and/or Misdemeanor(s)
*
Location(s) of offense(s) (City & State)
*
Date(s) of offense(s) (MM/YYYY)
*
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?
*
Yes
No
If "Yes" - List any/all TYPES of insurance, Final Action(s), Reason(s), and Date(s):
*
Are you a member of the Military, Military Reserve or National Guard (active or inactive) or do you have a written agreement to become a member at a future date?
*
Yes
No
If "Yes" - List Current Duties AND Current Assignment Location
*
Have you been alerted or received orders for duty outside the U.S.?
*
Yes
No
Are you currently receiving, or within the next two years do you expect to receive, hazardous duty or incentive pay?
*
Yes
No
Within the next 2 years, do you plan to travel, work or reside outside the U.S.?
*
Yes
No
If "Yes" - List ALL of the following: City(ies), Country(ies), Departure Date(s), Lenght of Trip(s), and Purpose of Travel (Business, Pleasure, Military, Missionary, Visit Family/Friends, etc.)
*
Have you, in the past 2 years, flown as a student pilot, pilot or crew member (or do you plan to within the next 2 years)?
*
Yes
No
In the past two years, or in the next two years, select any/all of the activities you have taken part in, or that you plan to take part in:
*
Hang Gliding
Para Sailing
Para Kiting
Parachuting
Skydiving
Ultralight
Soaring
Ballooning
Bungee Jumping
Rock Or Mountain Climbing
Organized Racing By Automobile
Motorcycle
Powerboat Or Snowmobile
Underwater Diving
NONE of the Above
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MEDICAL HISTORY
Have you lost more than 15 pounds over the past 12 months?
*
Yes
No
If "Yes" - What was the weight lose due to, and how much weight have you lost over the past 12 months?
*
Do you have any congenital or birth disorders including Autisim, Blindness, Deafness, Missing Limb(s), Heart Defect, Down’s Syndrome, Spina Bifida, or any other congenital disorder?
*
Yes
No
IF YES, indicate which condition(s), list all medications, dosage, frequency, Year of Diagnosis, if you've been hospitalized for each condition in past 3 years, and Month and Year of last follow up with a physician regarding each condition.
*
Have you, in the past 5 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?
*
Yes
No
IF YES, indicate which condition(s), list all medications, dosage, frequency, Year of Diagnosis, if you've been hospitalized for each condition in past 3 years, and Month and Year of last follow up with a physician regarding each condition.
*
Have you, in the past 5 years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication for chest pain, angina, heart attack, heart murmur, stroke or transient ischemic attack/mini stroke (TIA), irregular heart beat/rhythm, other circulatory or heart disorder or coronary artery / heart disease / atherosclerosis?
*
Yes
No
IF YES, indicate which condition(s), list all medications, dosage, frequency, Year of Diagnosis, if you've been hospitalized for each condition in past 3 years, and Month and Year of last follow up with a physician regarding each condition.
*
Have you, in the past 5 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 including melanoma, leukemia, lymphoma, colon polyp, or any malignant or benign growth?
*
Yes
No
IF YES, indicate which condition(s), list all medications, dosage, frequency, Year of Diagnosis, if you've been hospitalized for each condition in past 3 years, and Month and Year of last follow up with a physician regarding each condition.
*
Have you, in the past 5 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?
*
Yes
No
IF YES, indicate which condition(s), list all medications, dosage, frequency, Year of Diagnosis, if you've been hospitalized for each condition in past 3 years, and Month and Year of last follow up with a physician regarding each condition.
*
Have you, in the past 5 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?
*
Yes
No
IF YES, indicate which condition(s), list all medications, dosage, frequency, Year of Diagnosis, if you've been hospitalized for each condition in past 3 years, and Month and Year of last follow up with a physician regarding each condition.
*
Have you, in the past 5 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?
*
Yes
No
IF YES, indicate which condition(s), list all medications, dosage, frequency, Year of Diagnosis, if you've been hospitalized for each condition in past 3 years, and Month and Year of last follow up with a physician regarding each condition.
*
Have you, in the past 5 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?
*
Yes
No
IF YES, indicate which condition(s), list all medications, dosage, frequency, Year of Diagnosis, if you've been hospitalized for each condition in past 3 years, and Month and Year of last follow up with a physician regarding each condition.
*
Have you, in the past 5 years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication for asthma, chronic obstructive pulmonary disease, emphysema, chronic bronchitis, sleep apnea or any other disease or disorder of the lungs or respiratory system?
*
Yes
No
IF YES, indicate which condition(s), list all medications, dosage, frequency, Year of Diagnosis, if you've been hospitalized for each condition in past 3 years, and Month and Year of last follow up with a physician regarding each condition.
*
Have you, in the past 5 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?
*
Yes
No
IF YES, indicate which condition(s), list all medications, dosage, frequency, Year of Diagnosis, if you've been hospitalized for each condition in past 3 years, and Month and Year of last follow up with a physician regarding each condition.
*
Have you, in the past 5 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, or Lupus?
*
Yes
No
IF YES, indicate which condition(s), list all medications, dosage, frequency, Year of Diagnosis, if you've been hospitalized for each condition in past 3 years, and Month and Year of last follow up with a physician regarding each condition.
*
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 Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC) or any other immune deficiency disorder; or have you tested positive for HIV antibodies or antigens?
*
Yes
No
IF YES, indicate which condition(s), list all medications, dosage, frequency, Year of Diagnosis, if you've been hospitalized for each condition in past 3 years, and Month and Year of last follow up with a physician regarding each condition.
*
Have you ever used, or been treated for the use of 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?
*
Yes
No
*IF YES, indicate which TYPE of drug, when was the last you used this/these drug(s), notate IF/WHEN you have undergone treatment for the use of this drug, and are you a member of Narcotics Anonymous or similar organization?
*
Have you ever been advised by a medical professional to reduce or stop drinking alcohol, or received treatment of any kind for the use of alcohol?
*
Yes
No
*IF YES, WHEN were you advised, and are you an active member of Alcoholics Anonymous or similar organization?
*
Do you currently drink alcoholic beverages?
*
Yes
No
If "Yes" - How many drinks, cans or glasses of alcoholic beverages do you drink on a weekly basis?
*
Less than 1
1 - 7
8 - 14
15 - 19
20 - 25
26 - 35
36 or more
Have you, in the past five years, been disabled, received disability income benefits, or been unable to work or perform and carry out your normal daily functions for any reason other than maternity leave or recovery from minor surgery?
*
Yes
No
*IF YES, what was the reason for your disability, the date disability began, and your release date to usual activity? Are you currently prescribed any medications for your disability?
*
Have you, in the past 5 years, been diagnosed by a member of the medical profession for any other illness, disease, or injury, NOT ALREADY INCLUDED in your answers to any of the preceding questions?
*
Yes
No
*IF YES, Please specify type of illness, disease or injury
*
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 advised to have surgery, biopsies, treatment or medical test that are not included in your answers to any of the preceding questions?
*
Yes
No
If "Yes", provide full details, date, and if available the physician name, address and phone number
*
Have you ever attempted suicide?
*
Yes
No
*IF YES, When was your last attempt, and was it more than once?
*
Are you currently hospitalized or confined to a nursing, assisted living, long term care or rehabilitation facility?
*
Yes
No
Are you bedridden, or receiving any professional nursing care or health care services in the home?
*
Yes
No
Have you been told by a member of the medical profession that you have a disease or disorder which will result in death within 24 months or less, or are you receiving oxygen therapy (not including treatment for Sleep Apnea)?
*
Yes
No
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FAMILY HISTORY
Is your Mother living?
*
Yes
No
Unknown
*IF YES, list Current AGE, and list any current Health Issues. If no current health issues, type "none"
*IF NO, list AGE at Death, and list CAUSE of Death.
Is your Father living?
*
Yes
No
Unknown
*IF YES, list Current AGE, and list any current Health Issues. If no current health issues, type "none"
*IF NO, list AGE at Death, and list CAUSE of Death.
Do you have any Siblings?
*
Yes
No
If Yes, How many siblings?
*
List if each sibling is Living, Decease, Unknown... and list each sibling's current age (or age at death), and any known diseases or health issues (or cause of death)
*
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PAYMENT INFORMATION
Choose one of the following Payment Options for this Life Application: (NOTE: unless the policy/application is for a quick issue life policy that does not require full underwriting, we normally will not take payment until IF or WHEN we get an approval, and IF or WHEN we agree on the Type of policy, the Amount of coverage, etc. This is simply to include payment information in the application if desired for ease and convenience.
Include Payment Information with this Application
Submit Payment Information at a later date
Name of Financial Banking Institution:
*
Indicate TYPE of Bank Account:
*
Individual Checking
Individual Savings
Business Checking
Business Savings
Routing Number:
*
Account Number:
*
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W-9
Acceptance:
*
Yes, Agree
No, Disagree
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CONSENT AND ACKNOWLEDGEMENT
Please check the box under each question agreeing to each consent and acknowledgement question.
Do you agree that all the information you have provided regarding the questions of this applicationon this phone call are true and correct to the best of your knowledge?
*
Yes, Agree
Do you agree andacknowledge that you are the Proposed Insured, Owner or Payor of this insurancepolicy?
*
Yes, Agree
Do you understand and agree that life insurance coverage is not guaranteed as a result of this application, and no coverage will be in effect until if or when the policy is issued, and the first premium has been paid?
*
Yes, Agree
Do you understand and agree that you are not accepting Temporary Insurance coverage, nor have you been provided a written illustration of this policy?
*
Yes, Agree
Do you agree to authorize any physician, practitioner, medical facility, insurance company, MIB, VA, and any consumer reporting agency to give to and provide to Farmers New World Life and any of the Farmers Group of Companies and their representatives, ANY medical and non-medical information regarding you and your medical condition, history, care, treatment, prescriptions, or advice, and any motor vehicle, financial, and criminal records for the next 24 months?
*
Yes, Agree
Do you agree and authorize Farmers New World Life to make a brief report of your personal health information to Medical Information Bureau?
*
Yes, Agree
IF/ONCE the application is approved and you agree to the premium amounts, do you authorize Farmers New World Life to draft your account (or charge your card) for payment, and issue any credits back to your account/card if needed?
*
Yes, Agree
Do you agree that your SSN you provided is correct, you are not subject to backup withholdings with the IRS, you are a US citizen, and you are applying for and agreeing to this electronic signature currently on Texas soil?
*
Yes, Agree
Do you agree to the use of an electronic signature, and do you agree that you are providing your electronic signature for this life application right now with the insurance agency's current location of Jefferson, TX?
*
Yes, Agree
Do you agree that this electronic signature you are providing shall be applied to the applicable forms and will not be used on inapplicable forms or for future transactions?
*
Yes, Agree
E-SIGNATURE
By signing below, you are agreeing to an electronic signature, and you are acknowledging this application for life insurance will be submitted to underwriting for review.
*
Submit
Submit
Should be Empty: