OurFarmersAgent_LifeInsuranceAdult
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  • Life Insurance Proposal for Adult (18 and over)
    Please complete the information below for a quick and easy insurance proposal!

    Note: All of the information you provide is protected and encrypted.
    It is only accessible by Charlie Sanchez Agency personnel. 

    • General Applicant Information 
    • Format: (000) 000-0000.
    • What is the best way to contact you? (select all that apply)*

    • Can we contact you based on ALL of your selection(s)?*
    • Date of Birth*
       / /
    • Driver's License Expiration Date
       - -
    • Is the purpose of this policy for business?
    • Have you filed for bankruptcy in the past 7 years?
    • How did you hear about us?

    • Family History 
    • Does the proposed insured have any life insurance active or pending?
    • Which type?*
    • Will the policy being applied for reduce or replace an existing policy?
    • In the past 90 days has the proposed insured been unable to perform normal duties for 15 or more days because of illness?
    • Have you experienced the death of a parent?
    • Have you experienced the death of a sibling?
    • Desired Monthly Draft Date
       - -
    • Type of Insurance, Beneficiary Information, and Right to Designate 
    • Type of Insurance Desired

    • Right to Designate?
    • Health History 
    • Date of last doctor's visit
       - -
    • 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 disorders?

    • Any health issues?
    • Date Diagnosed*
       - -
    • Have you been hospitalized in the past 3 years?
    • Do you have a Primary Physician?
    • Have you, in the past five 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.)?
    • Have you, in the past 10 years, had your driver's license suspended, revoked, pied guilty to, or been convicted of reckless driving, or driving under the influence (DUI/DWI)?
    • Have you, in the past five years, pled guilty to or had any other driving conviction(s) (e.g. speeding, cell phone/texting, accident, etc.)?
    • Have you, in the past 10 years, pied 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?
    • 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?
    • 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?
    • Have you been alerted or received orders for duty outside the US?
    • Are you currently receiving, or within the next two years do you expect to receive, hazardous duty or incentive pay?
    • Within the next two years, do you plan to travel, work or reside outside the US?
    • Have you, in the past two years, flown as a student pilot, pilot or crewmember (or do you plan to within the next two years)?
    • Have you, in the past two years, or do you plan to in the next two years, 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, power boat or snowmobile, or underwater diving?
    • Have you lost more than 15 pounds over the past 12 months?
    • Do you have any congenital or birth disorders including blindness, deafness, missing limb(s), heart defect, Down's Syndrome, Autism or any other congenital disorder?

    • Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical professions or hospitalized, or taken medication for:

      Answer the following questions based on this criteria:
    • High blood pressure or high cholesterol/hyperlipidemia?
    • 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/atheroscl erosis?
    • Cancer, tumor, mass, skin cancer including melanoma, leukemia, lymphoma, colon polyp, or any malignant or benign growth?
    • 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?
    • Disorder of the liver, pancreas, digestive system or spleen including hepatitis, ulcers, intestinal bleeding, cirrhosis, fatty liver, or weight loss surgery?
    • Depression, anxiety, stress, eating disorder (anorexia or bulimia), post- traumatic stress, attention deficit/attention deficit hyperactivity, bipolar or other psychiatric or mental health disorder?
    • Seizures, paralysis, multiple sclerosis, memory loss or other disease or disorder of the nervous system?
    • Asthma, chronic obstructive pulmonary disease, emphysema, chronic bronchitis, sleep apnea or any other disease or disorder of the lungs or respiratory system?
    • Kidney, bladder, urinary, reproductive organ (other than contraceptive medication) or prostate disorder?
    • Arthritis, fibromyalgia, gout, back or joint pain or muscle disorder, or Lupus?
    • 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?
    • 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?
    • 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?
    • Do you currently drink alcoholic beverages?
    • 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?
    • Have you, in the past five years, been diagnosed by a member of the medical profession for any other illness, disease, or injury, not included in your answers to any of the preceding questions?
    • Have you, in the past five years, been admitted or advised to be admitted to any hospital or healthcare 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?
    • Have you ever attempted suicide?
    • Upload Supporting Documents 
    • Browse Files
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    • e-Signature 

    • During this process...


      Step 1. You agree to review all documents and disclosures.
      Step 2. You agree to read the Term of Use and Consent.
      Step 3. You acknowledge that you are a Proposed Insured, Owner or Payor of the insurance contract.
      Step 4. You agree to show proof of identification to me.

      I {applicantsName}, Proposed Insured acknowledge that I have agreed to steps 1 - 4. *

    • *

    • The proof of identification I gave to my agent, Charlie Sanchez, was: Driver's License

      State Issued: {stateDrivers}

      Driver's License Number: {driversLicense}

    • eSignature (Primary Insured/Owner/Agent)

      I acknowledge that I have read, or had read to me, and understand all of the forms presented for my review that are applicable to this application. I agree that the electronic signature I provide below shall be applied to the applicable forms and will not be used on inapplicable forms or for future transactions.

      {applicantsName}, Proposed Insured

       

    • Please review the application and all other forms in their entirety for accuracy, understanding and agreement. This application contains multiple pages and forms. An N/A next to any question or field indicates the question was not asked during the iGO e-Application process due to proposed insured’s age, face amount applied for and/or the specific product selected. Any response that does not fit onto the Part 1 or Part 2 application forms will print to the Overflow form document and will reference the form, section and question it refers to.
      After reading both documents, each party should check the box indicating they have been read.

      I, {applicantsName}, Proposed Insured, have read and agree to the Terms of Use and Consent and have reviewed the Application, disclosures and other items.

    • TERMS OF USE AND CONSENT

      CONDITIONS OF USE
      By using this website in relation to an application for insurance with Farmers New World Life Insurance Company, hereinafter referred to as "the Company", you agree with the following Terms of Use and Consent ("Terms") without limitation or qualification. Please read these Terms carefully before using this website. If you do not agree with these Terms, you are not granted permission to use this website and must exit this website immediately. The Company may revise these Terms at any time by updating this posting. You are bound by any such revisions and should therefore periodically visit this page to review the current Terms governing this website.

    • DISCLAIMER
      To the fullest extent permissible, the materials on this website are provided "as is" and without warranties of any kind, either expressed or implied, and the Company, and its officers, directors, employees and agents (which shall include career agents and brokers) (collectively "Representatives") and suppliers disclaim all warranties, expressed or implied, including, but not limited to, implied warranties of merchantability and fitness for a particular purpose. Neither the Company, nor its Representatives or suppliers, warrant that the functions contained in the materials will be uninterrupted or error-free, that defects will be corrected, or that this website, or the server that makes it available, are free of viruses or other harmful components. Neither the Company, nor its Representatives or suppliers, warrant or make any representations regarding the use or the results of the use of the materials on this website in terms of their correctness, accuracy, reliability, or otherwise. You (and neither the Company, nor its Representatives or suppliers) assume the entire cost of all necessary servicing, repair, or correction. The information and descriptions contained herein are not necessarily intended to be complete descriptions of all terms, exclusions and conditions applicable to the products and services, but are provided solely for general informational purposes; please refer to the actual policy or the relevant product or service agreement; this website may be linked to other websites which are not maintained by the Company. Neither the Company, nor its Representatives or suppliers, are responsible for the content of those websites. The inclusion of any link to such websites does not imply approval of, or endorsement by, the Company, or any of its Representatives or suppliers, of the websites or the content thereof.

      LIMITATION OF LIABILITY
      While the Company and its Representatives or suppliers use reasonable efforts to include accurate and up-to-date information on this website, errors or omissions may occur. Under no circumstances shall the Company, or its Representatives or suppliers, be liable to you for any direct, incidental, consequential, indirect, or punitive damages that result from the use of, or the inability to use, the materials on this website, even if advised of the possibility of such damages.

      JURISDICTION
      Unless otherwise expressly set forth herein, the Company and its Representatives make no representation that materials on this website are appropriate or available for use in any location. Those who choose to access this website do so at their own initiative. The offer to sell or buy a product is specifically limited to the jurisdiction(s) in which the Company and its Representatives have the authority to offer the insurance products described in this website. Some products and services may not be available in all jurisdictions.

      TRADEMARKS AND COPYRIGHTS
      All trademarks, service marks, trade names, logos, icons and images are proprietary to the Company or its Representatives or suppliers. Nothing contained on this website should be construed as granting, by implication, estoppel, or otherwise, any license or right to use any of the foregoing displayed on this website without the written permission of the Company, its Representatives or suppliers, as applicable. Your use of any of the foregoing displayed on this website, or any other content on this website, except as provided herein, is strictly prohibited and may violate copyright laws, trademark laws, the laws of privacy and publicity, and communications regulations and statutes.

      SOFTWARE LICENSES
      You acknowledge that any software which may be available or provided to you on this website may contain technology that is subject to strict controls pursuant to export control laws and regulations of the United States of America and other countries and jurisdictions. You hereby agree that you will not transfer or export such software in violation of such applicable export laws and regulations. Neither the Company, nor its Representatives or suppliers, authorize the downloading or exportation of any software or technical data from this website to any jurisdiction prohibited by such export controls laws and regulations.

      CONSENT TO USE OF ELECTRONIC SIGNATURES AND RECEIPT OF CERTAIN DISCLOSURES EXCLUSIVELY THROUGH ELECTRONIC MEANS
      Thank you for using the electronic application process offered by Farmers New World Life Insurance Company. You are applying for insurance coverage using electronic records, transactions and signatures. The Company is legally required to provide you with certain disclosures and information about your insurance application ("Required Information"). If you give consent, we can deliver this Required Information to you electronically. Your consent also permits the general use of electronic records and electronic signatures in connection with your application. You must have access to a personal computer with appropriate computer hardware, software and internet access (your internet provider may charge for internet access) to access and view the documents. You may request paper copies of the completed documents at no charge at any time without revoking your electronic delivery election by calling 1-800- 238-9671. You can also revoke your electronic delivery selection at any time by calling 1-800-238-9671.

      Policy Owners of Variable Products Only
      In addition to the above application requirements, if you give consent, we can deliver subsequent variable life prospectus(es), fund company prospectus(es), semi-annual and annual reports, and supplements (collectively, the "documents") by electronic delivery. This may include, but is not limited to, PDF format, hyperlink, and/or a website the Company makes available to you. This consent is also subject to the same paper copy and revocation requirements outlined above.

    • PLEASE READ THIS NOTICE CAREFULLY. PRINT OR DOWNLOAD A COPY FOR YOUR RECORDS.

      Disclosures and Consent to Use of Electronic Signatures
      By electronically signing this document, you are agreeing to use of electronic transactions and electronic signatures on this website, and to receiving electronic versions of certain records. You are also agreeing to be held to any agreement you make or transmit through the Internet or this website, including your consent to receive the Required Information from us only by electronic transmission. You agree that, by using this website, your consent will be as legally binding and enforceable as if you had signed on paper. You are entitled to change your mind and withdraw your consent. However, you would then no longer be able to use this section of the website and you will not be able to complete your application electronically with the Company. If you also want a paper copy of the Required Information, but still want the Company to process your application electronically, we will still need your consent to receive Required Information electronically.
      If you consent to electronic delivery of Required Information and then decline the e-signature process, the Company cannot continue processing your application electronically.
      Your consent applies to all Required Information that the Company gives you, or receives from you, about your insurance application and the notices, disclosures, and other documents related to it.
      You agree to provide a valid email address and to keep us informed of any change in your email or mailing address during the eSignature process. You may update your email address by calling 1-800-238- 9671. We are not responsible for problems arising from emails sent to an inactive or out-of-date email address, unless we are solely negligent for using an incorrect address.
      If an email is returned as undeliverable, we may contact you to confirm your email address or we will provide Required Information to your postal address via USPS.
      You agree to review Required Information by opening, printing or downloading Required Information for your records when we advise you to. If you have any trouble opening, printing or downloading any Required Information, contact your Agent at the address or telephone number given to you when you applied for coverage.
      The computer hardware and software used to access this website on the Internet is all you will need to access the application for insurance, related notices, disclosures, authorizations, acknowledgements and other documents provided to you in electronic form. To retain copies of these documents, you may 1) print them from this website, 2) email them to an address where you can print them on paper, or 3) save an electronic copy onto a computer with at least 100 megabytes of memory.
      If you do not have the required software and/or hardware, or if you do not wish to use electronic records and signatures for any other reason, you can ask the Company to send you paper copies of the completed application document(s) instead. The Company may require that certain communications from you be delivered to them on paper at a specified address.
      Should we make any changes to hardware or software requirements for electronic delivery such that you will no longer be capable of accessing or retaining your documents electronically, we will inform you of the revised hardware and software requirements. You will be requested to review the revised Terms and your continued enrollment will serve as your consent to continue participating in the electronic delivery option according to the new requirements.

      We reserve the right to modify these electronic delivery Terms at any time. Your continued participation in electronic delivery during this application process will constitute your acceptance of any revisions to these Terms.

      We are not required to deliver information electronically and may discontinue electronic delivery in whole or in part at any time.

    • IMPORTANT STATE SPECIFIC DISCLOSURES AND CONSENT LANGUAGE
      Specific disclosures and consent language may be required by certain states. Please read the disclosures or consent language below applicable to the state for which your policy is issued.

      GEORGIA:
      For policyholders of the state of Georgia who have elected to receive all mailings and communications electronically, you hereby agree as follows:
      I AGREE TO RECEIVE ALL MAILINGS AND COMMUNICATIONS ELECTRONICALLY. SUCH ELECTRONIC MAILING OR COMMUNICATIONS MAY EVEN INCLUDE CANCELLATION OR NONRENEWAL NOTICES.

      KENTUCKY, TENNESSEE:
      The policyholder who elects to allow for selected policy documents, available notices and communications to be sent to the electronic mail address provided by the policyholder should be aware that the election operates as consent by the policyholder for notices to be sent electronically, which may include notice of nonrenewal and cancellation. Therefore, the policyholder should be diligent in updating the electronic mail address provided to the insurer in the event that the address should change.

      ALL STATES:
      Statement of Consent
      I confirm that:

      • I can access and read the Terms of Use and Consent;
      • My email address I want FNWL to use to send electronic communications is listed below:
        I have an email service provider, am able to send email and receive email with hyperlinks to websites with attached files, and will maintain a current email address on file with FNWL;
      • Until or unless I notify the Company as described above, I consent, if applicable, to receive all required notices and disclosures relating to my insurance application exclusively through electronic means;
      • Variable application only – If I select “yes” in Section G of the Variable Application supplement, I consent to receive Variable documents through electronic means; and,
      • I also consent to the use of electronic signatures in place of handwritten signatures, in connection with this insurance application with the Company.
    • Submit Form 
    •  

    • Charlie Sanchez Insurance Agency
      Office (call or text): 512-251-7847
      Fax: 512-341-9797
      Email: Insurance@CharlieSanchez.com 
      Web Site: CharlieSanchez.com 

    • Charlie Sanchez
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