Insurance Application

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Fill our the application questions below and one of our team members will reach out to you directly to review your customized plan.

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