E-app Fact Finder
Client Information
Name:
Phone Number:
Format: (000) 000-0000.
Address:
Date of Birth:
-
Month
-
Day
Year
Date
Social Security Number:
Driver License #:
State:
Are you a citizen of:
USA
Other
E-mail:
example@example.com
State/Country:
1. Have you ever had a driver's license suspended, revoked or restricted?
Y
N
2. Have you, in the last 5 years, been convicted of, or pled guilty or no contest to, reckless or negligent driving, two or more moving violations or driving under the influence of alcohol or drugs?
Y
N
3. Have you, in the last 2 years, been disabled for 2 or more weeks?
Y
N
4. Have you ever had an application for life or health insurance declined or postponed, required an extra premium or other modification or had a life or health policy or contract that was cancelled, recalled, or denied renewal?
Y
N
5. Have you, in the last 10 years, been convicted of, or pled guilty or no contest to, a felony, or are current felony charges pending?
Y
N
6. Do you have any plans to travel or reside outside the United States or Canada in the next year (other than a two-week or less vacation to Western Europe or the Caribbean)?
Y
N
7. Have you, in the last year, flown other than as a passenger or do you plan to do so?
Y
N
8. Have you, in the last year, engaged in or do you plan to engage in motor racing on land or water, underwater diving, skydiving, ballooning, hang gliding, parachuting, or flying ultra-light aircraft or other hazardous sports or hobbies?
Y
N
9. Are you or is the Owner(s) an Active Duty Member of the Armed Forces?
Y
N
10. Have you ever filed bankruptcy?
Y
N
Y
N
12. Have you ever used tobacco or nicotine products in any form (including but not limited to: Cigarettes, cigars, cigarillos, pipe, chewing tobacco, nicotine patches or gum)? If Yes provide details below
Y
N
Cigarettes:
Other:
Date Stopped:
Cigars:
Current/Past:
Product Quantity:
Chewing Tobacco:
# Years:
Increase Life Company of America
7335 Highway 6 South Ste 250
Missouri City, Texas 77459
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Doctor Information
Doctor's Name:
Birth Place:
Doctor's Address:
Exam Date:
-
Month
-
Day
Year
Date
Doctor's Phone Number:
Format: (000) 000-0000.
Exam Time:
Hour Minutes
AM
PM
AM/PM Option
Height:
Weight:
Have you gained weight in the last 12 months?
Yes
No
Father: known to the insured?
Yes
No
Age if living:
Age at Death:
Mother: known to the insured?
Yes
No
Age if living:
Age at Death:
Beneficiary Information
Name:
Phone Number:
Format: (000) 000-0000.
Address:
Social Security Number:
Percentage:
Relationship to You:
Relationship to You:
Primary
Contingent
Beneficiary Information (addt'l)
Name:
Phone Number:
Format: (000) 000-0000.
Address:
Social Security Number:
Percentage:
Relationship to You:
Relationship to You:
Primary
Contingent
Banking Information
Bank Name:
Account Number:
Routing Number:
Checking Savings
Checking
Savings
Policy Information
Policy Amount:
Product Name:
Employer:
Time employed:
<6 months
6 months
Annual Income:
Net Worth:
Household Annual Income:
Household Net Worth:
(exp. 04/18)
Increase Life Company of America
7335 Highway 6 South Ste 250
Missouri City, Texas 77459
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