OurFarmersAgent_LifeInsuranceYouth
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  • Life Insurance Proposal for Youth (17 and under)
    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. 

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

    • Can we contact you based on your selection(s)? AND Opt IN or Opt OUT to receive Text Messages*
    • Date of Birth*
       / /
    • Driver's License Expiration Date
       / /
    • Have you filed for bankruptcy in the past 7 years?
    • Is the purpose of this policy for business?
    • 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, and Child's Information 
    • 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?
    • 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?
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    • Charlie Sanchez Insurance Agency
      Office (call or text): 512-251-7847
      Fax: 512-341-9797
      Email: Insurance@CharlieSanchez.com 
      Web Site: CharlieSanchez.com 

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