iCL Assurance ~ Living Benefits Analysis

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First Name

Last Name

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Date of Submission* This field is required.

Date

Hour

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Qualifying Policy Holder's Name:* This field is required.If you are the Policy Holder to be insured, then just click "NEXT" If you are not intending to be the policy holder, please provide policy holder's full name as it is to be registered with the insurance provider.

First Name

Last Name

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Qualifying Policy Holder's Date of Birth* This field is required.

Date

Your Relationship to the Qualifying Policy Holder to be Insured* This field is required.

The Insured Party is My:

The Insured Party Sex is:

The Current Health of the Insured Party is:

Has the Qualifying Policy Holder Ever Been Administered any of the FollowingCHECK ALL TREATMENTS that apply:

COVID Tested (Corona Virus)

COVID-19 Vaccine (Corona Virus)

Flu Vaccine (H1N1)

Hepatitis A Vaccine

Hepatitis B Vaccine

IV (Human Immunodeficiency Virus)

HPV (Human Papillomavirus) Vaccine

Meningococcal Vaccine

MMR (Measles, Mumps, Rubella) Vaccine

Pneumococcal Vaccine

Shingles (Zoster) Vaccine

Tetanus, Diphtheria, Pertussis (Td, Tdap) Vaccine

Varicella (Chickenpox) Vaccine

NEVER BEEN VACCINATED

Other

Has the Qualifying Policy Holder Ever Been Diagnosed with the FollowingCHECK ALL DIAGNOSIS that apply, leave blank if none apply:

ALS (Lou Gehrig's Disease)

Alzheimer's Disease or Dementia

Cancer

Chronic Lung or Respiratory Disease

COVID19

Heart Disease (Including Pulse or Rhythm Issues)

Insulin Dependent Diabetes

Liver Disease

Multiple Sclerosis (MS)

Parkinson's Disease

Stroke / Cerebrovascular Disease

Other

Please provide any additional health information for the Qualifying Policy Holder:If there are any existing conditions which were not listed previously, please describe here.

Does the Qualifying Policy Holder use any assistive devices or ongoing medial support such as homecare, hospice, or continuous therapy?* This field is required.

YESNO

Do you have another life insurance policy that you would like to qualify?If "YES" then please submit additional qualification form after fully completing and submitting this analysis.

YESNO

Relationship & Royalty Sharing Covenant* This field is required.By Digitally Signing below, I agree to holding a Relationship & Royalty Sharing Covenant together with all Policies & Agreements of iCovest. DISCLAIMER: Information you receive which is provided by iCovest is solely based on the information you provided. Initial strategies presented through iCovest online or personal counsel are not binding estimates of performance because we are not able to verify your identity. Your final strategy and capital performance may differ when you close with an iCovest qualified financial professional; however, it is iCovest's Code of Conduct, Policies & Agreements to provide you with accurate information based on your stated information. By proceeding to enter your data, and Submitting it to iCovest FBO, you agree to be matched with an iCovest Strategic Philanthropist, and consent (not required as a condition any goods and/or services) for us and/or them to contact you (including through automated means; e.g. autodialing, text and pre-recorded messaging) via telephone, mobile device (including SMS and MMS), and/or email, even if you are on a corporate, state or national do not call registry. IMPORTANT MESSAGE: iCovest FBO presents the iCovest Life program on this "website" which is owned and operated by iCovest F.B.O., an Ecclesiastical State Integrated Auxiliary operating by rule of necessity as Unincorporated Association (herein, “iCovest”). We are a Faith Based Organization qualified and operating under Title 26 U.S. Code § 508c(1)a Non-Assumptive 28 U.S. Code § 1746 (1). By accessing the website and any pages thereof, you agree to the binding terms of use of all iCovest Policies & Agreements, as each may be amended from time to time. iCovest is not a registered broker, dealer, investment adviser, investment manager or registered funding portal. Any and all private offerings on this site are available without contravention of Rule 506(b) of Regulation D, as “safe harbor” under Section 4(a)(2) of the Securities Act, and pursuant to the iCovestor Relationship & Royalty Sharing Covenant made in acquiescence at the time of any like kind exchange for any goods, services, and/or subscription made in the medium and measurement of silver in the form of authorized government minted 1 ounce silver legal tender coined money (Measured Digitally and/or Physically exchanged thereof as an Intentional Community Opportunity (-ies), a.k.a. “ICO” or "ICOs"). The information contained on this site is provided for informational purposes as a service to the public as part of the mission of the iCovest and does not constitute legal or tax advice. Legal Information is not the same as Legal Advice. Some of the information on this site and corresponding emails provide information about law designed to help users safely cope with their own Faith Based Organization needs. The application of law varies depending on many circumstances. The laws of every state are in constant change, and although we go to great lengths to make sure our information is accurate and useful, we recommend you consult a lawyer if you want professional assurance that this educational information, and your interpretation of it, is appropriate to your particular situation.

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iCL Assurance ~ Living Benefits Analysis