• Complete Whole Life Application

    1st Day Coverage Guaranteed Issue Ages 18-70. This is a group whole Life Plan sold to individuals.
  • Who is completing this application?*

  • Complete Whole Life - How much insurance do you want to purchase?

    You would have received this information in the result from your quote submission as well as it would have been in the auto-response email after your quote submission. Please enter accordingly.
  • Format: (000) 000-0000.
  • May we text you with updates regarding your application/policy?*
  • Date of Birth*
     - -
  • Gender*
  • Have you used tobacco in the last 12 months?*
  • Do you certify that you are actively at work now, for wage or profit, and you have worked at least 20 hours each week performing all duties of your regular occupation at your regular place of employment for at least the last 3 months except for minor illness or injury of 1 week or less, or normal pregnancy.*
  • Are you self-employed?*
  • Format: (000) 000-0000.
  • Have you been told by a member of the medical profession that you have a life expectancy of 12 months or less?*
  • Are you currently being treated for any form of internal cancer?*

  • Dear {applicantsName},Thank you for your interest in this insurance product. Unfortunately we are unable to process your application at this time. 

  • Existing Life Insurance

    Important: This group policy is for additional Life Insurance or New Life Insurance Coverage!
  • Do you have an existing The Standard, American Heritage Life Insurance Company Policy?*

  • Available Riders

    Spouse & Child Riders

  • If adding a Spouse Rider. - NOTE: Spouse must certify that they are actively at work now, for wage or profit, and they have worked at least 20 hours each week performing all duties of my regular occupation at their regular place of employment for at least the last 3 months except for minor illness or injury of 1 week or less, or normal pregnancy.* ELIGIBLE for 1 of 3 amounts, $10,000, $20,000 or $30,000 if working. Only $10,000 if not working.

  • Do you wish to add a Spouse Rider?*

  • Since you do not have a Spouse Rider, please continue to the next page.

  • Spouse Rider Information

  • How much coverage do you want for your spouse? If working, allowed coverage amounts of $10,000, $20,000, or $30,000.*
  • Does this spouse reside at the same address of the primary insured?*

  • Spouse Existing Insurance

    Important: This group policy is for additional Life Insurance or New Life Insurance Coverage!
  • Does your spouse have any existing "The Standard" Insurance Policy?*
  • Spouse Date of Birth*
     - -
  • Gender*
  • Has your spouse used tobacco in the last 12 months?*
  • Do you certify that your spouse is actively at work now, for wage or profit, and has worked at least 20 hours each week performing all duties of their regular occupation at their regular place of employment for at least the last 3 months except for minor illness or injury of 1 week or less, or normal pregnancy.*
  • Spouse Beneficiary Date of Birth*
     - -
  • Gender*
  • Would you like to add an additional Spouse Primary Beneficiary?*
  • Additional Spouse Beneficiary Date of Birth
     - -
  • Gender*
  • Would you like to add a Contingent Beneficiary?*
  • Additional Spouse Contingent Beneficiary Date of Birth
     - -
  • Gender
  • Do you have an additional Contingent Beneficiary you would like to add ?
  • Gender

  • Child Rider Information

  • Child Rider - If YES, ALL children 18 years old and under receive $20,000 of coverage each. The cost per month to cover ALL Children is only $9.10 per month. Coverage is extended to Children under age 26 if still in School.

  • Do you wish to add a Child Rider? Note: ALL Children are covered for $20,000 for $9.10 per month.*
  • Date of Birth
     - -
  • Gender
  • Does this child reside at the same address as the primary insured?
  • Date of Birth
     - -
  • Gender
  • Does this child reside at the same address as the primary insured?
  • Date of Birth
     - -
  • Gender
  • Does this child reside at the same address as the primary insured?
  • Date of Birth
     - -
  • Gender
  • Does this child reside at the same address as the primary insured?
  • Date of Birth
     - -
  • Gender
  • Does this child reside at the same address as the primary insured?
  • Date of Birth
     - -
  • Gender
  • Does this child reside at the same address as the primary insured?
  • The Primary Beneficiary for all children will be the Primary Insured. If you would like to add a Contingent Beneficiary, provide their name, date of birth, and relationship. Would you like to add a Contingent Beneficiary?
  • Contingent Beneficiary date of birth?
     - -

  • Billing Information

  • Are you paying for your own policy?*

  • Payor Details

  • ACH Banking Information

  • What type of Bank Account is this?*

  • IMPORTANT: Policy Effective Dates and Payment Method

    Payment must be made between the day of enrollment and the 24th of the month to have an effective date of the following month.

  • Primary Beneficiary

    Total paid to Beneficiary(s) must total 100%.
  • Primary Beneficiary Date of Birth*
     - -
  • Gender*
  • Would you like to add an additional Primary Beneficiary?*
  • Additional Primary Beneficiary Date of Birth
     - -
  • Gender*
  • Would you like to add a Contingent Beneficiary?

  • Contingent Beneficiary(s)

    Total paid to Beneficiary(s) must total 100%.
  • Contingent Beneficiary Birthdate
     - -
  • Gender*
  • Would you like to add an additional Contingent Beneficiary?
  • Contingent Beneficiary Birthdate (Additional)
     - -
  • Gender (Additional)*

  • Based on the information you have provided, you should qualify for the Complete Whole Life Insurance policy.

     

  • Mandatory Disclosures

    Please read each of the following disclosures and agree and sign to be able to continue your application process.

  • The Standard, American Heritage Life Insurance Company Agreement

  • You must read and agree to the "The Standard" Agreement. 

    Please view this agreement at THIS LINK.

  • Date
     - -

  • SUMMARY and DISCLOSURE STATEMENT for ACCELERATED DEATH BENEFIT FOR CHRONIC ILLNESS RIDER

  • You must read and agree to the SUMMARY and DISCLOSURE STATEMENT for ACCELERATED DEATH BENEFIT FOR CHRONIC ILLNESS RIDER Agreement. 

    Please view this agreement at THIS LINK.

  • Date
     - -

  • SUMMARY and DISCLOSURE STATEMENT for ACCELERATED DEATH BENEFIT FOR TERMINAL ILLNESS OR CONDITION RIDER

  • You must read and agree to the SUMMARY and DISCLOSURE STATEMENT for ACCELERATED DEATH BENEFIT FOR TERMINAL ILLNESS OR CONDITION RIDER Agreement. 

    Please view this agreement at THIS LINK.

  • Date
     - -

  • Final STATEMENT and any Questions

  • Today's Date
     - -
  • Should be Empty: