Life Insurance Application - Co-Applicant
Full Legal Name
First Name
Middle Name
Last Name
Suffix
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Citizenship
U.S. Citizen
Not a Citizen
Temporary Status
Non-Immigrant Visa
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Why do you think Insurance Coverage is a good thing for you and your family?
What type of life insurance do you have?
I don't have any life insurance
I have term life
I have whole life
I have something else, or a mix of insurance
Is your life insurance work-sponsored or self-owned?
Work-Sponsored
Self-Owned
Other
What is the amount of the death benefit?
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Employment Status
Self-Employed
Retired
Full Time
Part Time
Unemployed
Job Title
Hours Worked per Week
Annual Income
How many children do you have, and what are their ages?
Have you received any disability or worker's comp pay in the last 5 years? Please list details including military, government issued, etc. (military please include the percentage)
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Height and Weight
Tobacco Use
Smoke
Chew
Vape
Quit
Never Used
When did you quit (leave blank if still using or never used)?
-
Month
-
Day
Year
Date
Marijuana use in any form
Yes
No
Have you ever had to undergo treatment for drug, alcohol or prescription drug abuse?
Yes
No
Explain the details of why treatment was needed
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Do you have any minor health concerns such as high blood pressure or high cholesterol?
Yes
No
Explain the minor health concern
Do you have any major health concerns (history of cancer, strokes, heart problems, diabetes, kidney or liver issues)?
Yes
No
Explain the major health concern
Do you any respiratory concerns such as asthma, sleep apnea, COPD?
Yes
No
Explain the respiratory health concern
Do you struggle with any sort of depression, anxiety, PTSD, bipolar or any other personality disorders?
Yes
No
Explain the mental health concern, listing details because the insurance companies can see our records
List all prescription medications that you are or have been taking on a regular basis in the last 10 years (I don't need the dosage, just the names).
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Have you had any surgeries or hospitalizations for longer than 24 hours in the last 10 years? (details please)
Have you ever had a suspended driver's license, reckless driving, DUI or anything like that? If so, list which one(s).
Have you ever been convicted of a felony or misdemeanor (select ALL that apply)?
Yes, convicted of a felony
Yes, convicted of a misdemeanor
Never been convicted
Do you have a home loan / mortgage?
Yes
No
What is the amount of your most recent home loan?
How many years are left on this loan?
Do you have any other home loans, in addition to your most recent one?
Yes
No
What is the balance of your other home loans?
What is your monthly loan payment with taxes and escrow included? (All Loans)
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