Barry's test page3

2023-life-insurance-application

Country Of Transaction:

Practice Application? YesNo

First Name:

Middle Initial:

Last Name

Primary Address:

Address 1

Address 2

City

State

Zip Code

Is this your mailing address? YesNo

Residence Phone:

Mobile Phone:

Email:

Gender: MaleFemale

Date of Birth:

Marital Status: MarriedDivorcedLegally SeparatedSingle-Not Married

Have you lived in the US all your life? YesNo

Do you have a driver’s license? YesNo

Are you employed? YesNo

Gross Mo. Earnings

Policy Owner Information:

First Name

Last Name

Or Other IndividualTrustBuy-Sell AgreementBusiness

Beneficiary Information:

First Name

Last Name

Middle Initial:

Allocation %

Relationship to insured.

**Important! A Minor Beneficiary does not have the legal capacity to provide a valid release for the proceeds of a life insurance policy, and as a result a court must appoint a financial guardian. This procedure involves additional expenses for the minor beneficiary and may delay the payment of proceeds. Please consult with your estate or tax advisor about other ways to give the proceeds of your insurance policy to a minor.

Contingent Beneficiary:

First Name

Last Name

Middle Initial:

Allocation %

Relationship to insured.

Medical Questions

Primary Beneficiary:

Height (ft.)

Height(in)

Weight:

Has Tobacco/nicotine been used in the past 5 years? YesNo

Hypertension? YesNo

Stroke; diabetes; cancer; tumor; paralysis; multiple sclerosis; lupus; scleroderma; rheumatoid arthritis; muscular dystrophy; leukemia; lymphoma (Hodgkin’s and Non-Hodgkin’s); seizure; mental or nervous disorder? YesNo

Any disease or disorder of the heart (excluding hypertension); liver (including hepatitis); pancreas; blood; brain; kidneys; circulatory; respiratory (including sleep apnea); gastrointestinal; neurological or nervous system? YesNo

Received professional counseling or medical treatment due to the use of alcohol or drugs (including prescription drugs)? YesNo

Used illegal or illegally obtained drugs (including prescription drugs); or been convicted of a drug or alcohol related charge? YesNo

Pleaded guilty to or been convicted of a felony; or have any pending felony charges? YesNo

Within The Past 5 years, has any person named in this application: Received disability benefits for a period of 6 months or longer or is currently receiving disability benefits (except for partial military disability or maternity)? YesNo

Within The Past 3 years, has any person named in this application: Pleaded guilty to or been convicted of a DUI or DWI (driving under the influence or driving while intoxicated) or two or more moving violations? YesNo

Flown as a pilot, student pilot, or crew member on any aircraft (other than commercial); or intend to do so within the next 2 years? YesNo

Engaged in any recreational activity, such as: scuba diving (excluding snorkeling), mountain climbing, parachuting, hang gliding, or racing of automobiles, motorcycles, snowmobiles, or boats, or intend to do so within the next 2 years? YesNo

Within the past 12 months, has any person named in this application: Been hospitalized for any reason for more than 24 hours other than childbirth? YesNo

Except for testes related to Human Immunodeficiency Virus (AIDS Virus), received medical testing with results not yet reported? YesNo

Except for tests related to Human Immunodeficiency Virus (AIDS Virus), been advised to receive medical testing, or treatment that has not yet been completed? YesNo

Have any plans within the next two years to reside outside of the United States or Canada for 30 days or longer? YesNo

Had a parent who died prior to age 65 as a result of cardiovascular illness or cancer? YesNo

In the event of a positive HIV test result, would you like for us to submit your results to your physician? YesNo

Do any of the persons applying for coverage have existing life insurance or annuities in force? YesNo

Do you want the “Important Notice: Replacement of Life Insurance or Annuities” read aloud to you? YesNo

Will replacement of existing insurance or annuity on any proposed insured occur? YesNo

2023-new-agent-sign-up

Primary Address:

Address 1

Address 2

City

State

Zip Code

Is this your mailing address? YesNo

More about yourself:

What Language do you speak at home?

Highest Education Level:

Recruit’s Average Annual Income:

Total Average Annual Income:

Ethno-Racial Origin of your family?

Are you currently employed? YesNo

Do you work in any of the following areas? InsuranceFinancial Services/InvestmentsBankingLending or Credit ServicesReal EstateLegal ServicesGovernmentNone of the above

Regardless of outcome, have you ever been charged with or pled guilty, no contest or no contendere to, or been found guilty of any felony crime in any court in the US or any other country? YesNo

Regardless of outcome, have you ever been charged with or pled guilty, no contest or no contendere to, or been found guilty of any crime in a state, federal or military court in the US or any other country of a non-felony involving misconduct? YesNo

Are you now or have you ever been EITHER the subject of any civil court, regulatory or administrative agency action involving allegations of misconduct? OR Have you ever been discharged or permitted to resign from any contract position or employment (including a military position) following allegations of misconduct? YesNo

Have you Either been barred, expelled, or suspended from engaging in a trade, professional or government contract by court order, injunction or otherwise? OR Have you had a trade or professional license denied, revoked, suspended, or restricted? YesNo

Have you ever had a bonding company deny, pay out on, or revoke a bond on you? YesNo

Financial:

Do you have unsatisfied judgment(s) against you? YesNo

Have you made a compromise with Creditors (other than the IRS) within the last 10 years? YesNo

Do you have unsatisfied lien(s) (taxes, mechanics, other) against you? YesNo

In the last 10 years, have you filed bankruptcy? YesNo

In the last 10 years, did an organization over which you had control file bankruptcy? YesNo

Military Status: VeteranActive MilitaryDOD CivilianNo Military Service

2023-general-inquiries-form

First Name(req)

Last Name(req)

Email Address(req)

Phone Number(req)

State(req)

To better assist you please enter your date of birth(req)

Choose Your Topic: (Req) WebsiteEmailPolicyClaimsI have a suggestionI have a Comment

Subject: (REQ) Share your question, request of comments with us and include any related details:

2023-insurance-for-home-form

First Name

Last Name

Date Of Birth

Phone Number

Business Street Address:

City

State

Zipcode

Appointment Language:

Outbound Customer Consent: YesNo

Appointment Notes (do not send sensitive information)

2023-small-business-insurance-form

Select the type of coverage you are looking for (Check all that apply) General LiabilityBusiness Owners PolicyWorkers CompensationCommercial AutoPL- E&O

Are you currently Insured? YesNo

What does your business do?

Business Name:

Business Website:

Business Entity Type: AssociationCorporationIndividualLLCPC

Business Street Address:

City

State

Zipcode

Year business was established:

First Name:

Last Name:

Phone Number:

Email Address:

Answer Financial and/or partners would like to call you regarding this inquiry. Do you consent to being called? YesNo

Comments:

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