Request an IUL Application
Ready to find out if an IUL is right for you? This form is a no-cost, no-obligation way to begin the application process. We'll use your details to get an official rate and offer. Rest assured, your information is protected with advanced encryption and HIPAA compliance. After you submit, we'll handle the rest and guide you through the next steps.
Let's Design Your IUL Plan 🏦
How do you plan to initially fund your IUL?
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Set up automatic monthly contributions
Make a lump sum payment
Both monthly contributions and a lump sum
I'm not sure yet
What amount would you like to contribute each month?
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How much would you like to contribute as a lump sum?
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What's the most you think you might invest annually?
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In a worst-case scenario, what's the minimum you could maintain monthly to keep the IUL from lapsing?
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What are your main goals for this IUL policy?
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Please Select
Tax-free retirement income
Lifetime insurance protection for my family
I'm unsure
How long do you plan on funding your IUL? For a specific number of years, until a certain age, or for life?
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What age do you plan to start drawing retirement income?
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Which is more important to you?
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Please Select
Maximizing the policy's potential for cash value growth.
Ensuring the death benefit remains stable and never decreases.
I'm not sure, I'd like to learn more.
What is the desired face amount for your policy?
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Please Select
$100,000
$250,000
$500,000
Other amount
Unsure
Other desired face amount?
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Do you already have an IUL Basics Expert?
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Please Select
Not yet
Jesse & Davina Wood
Allison Wiseman
Alyssa & Graham Goodman
Amanda Carter
Charles & Myra Lyons
Jessica Estrada
Kathryn Coster
Kyle Porter& Gena Robertson
Rebecca & Stephen Feigen
Is there someone we should thank for referring you?
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Client Information 👋
Please provide your personal information for the application.
Legal Name
First Name
Last Name
SSN/Tax ID#
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Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status
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Please Select
Single
Married
Divorced
Widowed
Do you have a former name?
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Yes
No
Former Name:
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Date of Birth
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-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender Assigned at Birth
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Male
Female
State of birth or country if outside the U.S.
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Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Driver's License Number
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Driver's License State
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Occupation
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Employer Name
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Employer Address
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Annual Household Income (approx.)
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Estimated Net Worth
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Are you a U.S. Citizen?
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Yes
No
Citizenship Status
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Green Card Holder
Visa Holder
Other
Visa Type
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What is your status?
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Issue Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expiration Date
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-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Beneficiary Information 🪦
A key benefit of an IUL is providing for your loved ones. To set up your policy, please tell us who you would like to be your primary beneficiary. Don't worry, you can easily add additional beneficiaries or make changes to this information at any time in the future.
Legal Name
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First Name
Last Name
Relationship to Insured
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Phone Number
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Date of Birth
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SSN/Tax ID#
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Bank Information 🏦
To complete your application, we need the banking information for the account you plan on using for your IUL. Your IUL provider requires this on the application to prove that you are a serious applicant and plan to move forward with funding if your policy is approved. No bank drafts will be made until you give us your explicit permission.
Bank Name
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Account Type
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Please Select
Checking
Savings
Account Number
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Routing Number
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Your Health & Habits 🏃♀️
This section helps us understand your overall health and lifestyle for underwriting.
Height
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Weight
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In the last 5 years, have you used nicotine or tobacco in any form (including recreational marijuana)?
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Yes
No
Please provide details on your tobacco/nicotine/marijuana use, including type, frequency, and date you last used.
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In the last 3 years, have you had more than one moving violation?
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Yes
No
In the last 5 years, have you had a DUI or DWI conviction?
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Yes
No
Do you have a history of drug or alcohol abuse in the last 10 years?
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Yes
No
Have you had a felony conviction in the last 10 years?
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Yes
No
Provide details & approximate dates for all YES answers.
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Do you participate in any hazardous activities or hobbies?
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Yes
No
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Hazardous Hobbies 🧗♂️
Please provide details on any hazardous hobbies you participate in.
Do you participate in aviation?
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Yes
No
Aviation Details
Experience
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Type of flying
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Yearly hours logged
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Total solo hours logged
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Aircraft flown
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Do you participate in skydiving/parachuting?
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Yes
No
Skydiving Details
Experience
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Number of jumps
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Do you participate in racing (e.g., cars, trucks, motorcycles, boats)?
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Yes
No
Racing Details
Speed/Type/Class
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Location
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Frequency
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Do you participate in scuba diving?
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Yes
No
Scuba Diving Details
Experience
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Type/class
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Depth of dives
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Frequency
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Location
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Do you participate in climbing and mountaineering?
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Yes
No
Climbing Details
Experience
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Height, length, grade and rating of climbs
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Location
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Equipment used
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Your Health History 🩺
Please provide details on your medical and family history.
Has a parent or sibling died prior to age 60 from cardiovascular disease or cancer?
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Yes
No
Have you ever had a history of coronary artery disease, diabetes, stroke, or cancer (other than basal cell skin cancer)?
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Yes
No
Have you ever been diagnosed with or treated for any of the following? (Select all that apply)
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Anxiety/Depression
Asthma
Cancer
Diabetes
Heart attack/bypass/angioplasty
Hepatitis
High blood pressure
Sleep apnea
None
Anxiety/Depression Details
Date of diagnosis?
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of last episode?
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Any related hospitalizations, ER visits, or urgent care visits?
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What related treatment have you received and when?
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History of suicide attempt?
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History of alcohol/substance abuse?
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Have you ever been seen or treated by a mental health professional?
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Name, address and phone number of physician(s) consulted?
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Asthma Details
Date of diagnosis and last attack?
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Type of asthma?
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What symptoms do you experience?
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Current medications?
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Dates of hospitalizations or ER visits?
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Have you ever used tobacco?
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Have you been diagnosed with any other respiratory disorder?
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Has a pulmonary function test ever been done?
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Name, address and phone number of physician(s) consulted?
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Cancer Details
Date of diagnosis?
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type or location of tumor?
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How was the cancer treated?
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Time since treatment last ended?
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What was the grade and stage?
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Any metastasis or nodal involvement?
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Any recurrence?
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Are you currently taking any medications?
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Do you have any other major health problems?
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Name, address and phone number of physician with complete records?
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Diabetes Details
Date of diagnosis?
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How are you being treated?
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Most recent blood glucose reading and HbA1c?
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Do you monitor your own blood sugar readings?
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Yes
No
Any medical complications related to diabetes?
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Symptoms or diagnosis of other related conditions?
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Have you smoked cigarettes in the past 12 months?
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Yes
No
How often do you see your physician?
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Name, address and phone number of physician with complete records?
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Heart Condition Details
Date chest pain first occurred?
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Final diagnosis?
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What tests were performed?
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Was a cardiac catheterization completed?
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Was a surgical procedure performed?
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Are you currently taking any medications?
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Recurrent chest pain or shortness of breath?
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Medical history of related conditions?
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Have you ever used tobacco?
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Name, address and phone number of physicians and hospitals consulted?
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Hepatitis Details
Date of first diagnosis?
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of hepatitis: A, B, C, D or E?
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What treatment have you received?
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Have you ever had a liver biopsy?
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Yes
No
Last imaging test and results?
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Name, address and phone number of physician(s) consulted?
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High Blood Pressure Details
Date of diagnosis?
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Last reading in your physician's office?
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Have you had any cardiac testing?
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Name, address and phone number of physician(s) consulted?
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Sleep Apnea Details
Date of diagnosis?
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Was it classified as mild, moderate or severe?
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What treatment have you received and are you compliant?
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Name, address and phone number of physician(s) consulted?
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Your Other Insurance
Please answer these questions about your existing and previous life insurance.
Do you currently have any other life insurance or annuity policies in force?
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Yes
No
Are you planning to cancel or reduce any existing life insurance policies if your IUL is approved?
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Yes
No
Company
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Policy Number
Amount of Coverage
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Year Issued
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Does it have cash value you plan on transferring to your IUL (1035 exchange)? How much?
Are you currently applying for life insurance with any other companies?
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Yes
No
In the last 3 years, have you had a life insurance or annuity policy that is no longer in force?
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Yes
No
Have you applied for life insurance in the last 12 months?
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Yes
No
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Confirmation & Submission
I confirm the information is true and accurate to the best of my knowledge.
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I confirm
I understand this is a preliminary assessment and not a binding policy.
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I understand
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