Application for TERM LIFE insurance

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Term life insurance provides coverage for 10, 20 or 30 years.

Referred by:

SECURE FORM

You're applying for $ Benefit, expected premium is $ mo.

[click to EDIT amount or age/gender]

INSURED First Name *

Middle

Last Name *

DOB *

Gender *

Female

Male

Beneficiary 1: FULL NAME *

Relationship *

DOB

Add more beneficiaries?

INSURED's INFORMATION:

Address: *

City *

State *

Zip *

Phone *

Email *

Driver license# *

Issued by *

US Citizen / resident? *

CITIZEN

Legal US resident

Height (FT) *

(in) *

Weight

SSN# *

Tobacco / nicotine user? *

Yes

Ever used marijuana/THC ? *

Yes - recreational

Yes - medical

Place of birth (STATE, City) *

Employment *

Employed

Self-employed

Unemployed

Disabled

Homemaker

Retired

Do you work a minimum 30 hours in your primary occupation? *

Yes

Occupation *

Annual income *

BENEFIT DETAILS

Benefit amount

Premium expected

Purpose of insurance

DATE to start *

Premium payment info

BANK NAME

ROUTING #

ACCOUNT #

Do you have any existing life insurance?

Yes

Medical & lifestyle questions - INSURED

I WILL ANSWER MEDICAL & LIFESTYLE QUESTIONS *

Answer medical questions NOW

I prefer to answer all medical questions ON THE PHONE with an underwriter

List your MEDICATIONS, dosage, reason *

During the last 10 years - have you been diagnosed or treated for:

1.a) Heart disorder, including a heart attack (myocardial infarction), angina, irregular heartbeat or abnormal heart rhythm (arrhythmia), chest pain, hypertension (high blood pressure), heart murmur, any blockage or narrowing of the arteries, any aneurysm, stroke or transient ischemic attack (TIA or mini-stroke), or rheumatic fever? *

No Yes

1.b) Diabetes, high blood sugar or sugar in the urine, anemia, blood or platelet disorders, elevated cholesterol, liver disease, hemophilia, kidney disease (other than kidney stones), protein or blood in the urine, Crohn’s disease, ulcerative colitis, disease or disorder of the stomach, gall bladder, bladder or prostate, other intestinal or digestive tract disease, or pancreatitis? *

No Yes

1.c) Internal cancer or tumor, cyst, melanoma, lymphoma, leukemia, disorder of lymph nodes or any glandular disorder? *

No Yes

1.d) Alzheimer’s disease, dementia, memory loss, seizures, mental retardation, Down's syndrome, multiple sclerosis (MS), muscular dystrophy (MD), Parkinson’s disease, amyotrophic lateral sclerosis (ALS), any brain or nervous system disorder, cerebral palsy or any form of muscular atrophy? *

No Yes

1.e) Sleep apnea, cystic fibrosis, emphysema or chronic obstructive pulmonary disease (COPD), shortness of breath, or asthma or other respiratory disorder? *

No Yes

1.f) Dizziness, fainting spells or anxiety, depression, chronic fatigue, eating disorders or any other psychological or emotional disorder? *

No Yes

1.g) Arthritis in any form, fibromyalgia, paralysis or connective tissue disorder (such as lupus or scleroderma) or any disease or disorder of the back, spine, bones, joints or muscles? *

No Yes

1.h) Varicose veins, varicose ulcer or phlebitis, syphilis or a hernia? *

No Yes

1.i) Any disease or disorder of the eyes, ears, nose or throat? *

No Yes

2.a) Required a transfusion of whole blood or blood products, including platelets, packed red blood cells or plasma? *

No Yes

2.b) Used controlled substances such as cocaine, heroin, amphetamines, barbiturates, hallucinogens or any other controlled substance not prescribed by a physician? *

No Yes

2.c) Been treated by a physician, or advised by a physician to seek treatment, for drug or alcohol use? *

No Yes

2.d) Been tested positive for exposure to the human immunodeficiency virus (HIV) infection or been diagnosed as having AIDS-related complex (ARC), or acquired immune deficiency syndrome (AIDS) caused by the HIV infection, or other sickness or condition derived from such infection? *

No Yes

During the last 5 years, have you:

3.a) Been a patient in any hospital, clinic, dependency program, halfway house or other medical facility? *

No Yes

3.b) Been advised to have any test, treatment, surgery, hospitalization or consultation with a medical professional which has not been completed, or for which results have not been received? *

No Yes

3.c) Had any special examinations or laboratory tests such as X-rays, electrocardiograms, blood tests or urine tests? *

No Yes

4. Have you had a natural parent or sibling who was diagnosed with or died of cancer, heart disease, diabetes, Huntington's disease or polycystic kidney disease prior to the age 60? *

No Yes

5.a) Have you ever been diagnosed, treated, tested positive for, or been given medical advice for any disorder of any genital or reproductive organ, or had a miscarriage, stillbirth or Cesarean section? *

No Yes

5.b) Are you currently pregnant? *

No Yes

6. Are you currently taking any prescription medication? *

No Yes

PHYSICIAN or clinic with the most current Dr. records? *

Date last seen? *

Reason for visit? *

Have you been tested positive, diagnosed or treated for AIDS or HIV in the past 10 years? *

Yes

Do you belong to or plan to join the military or National Guard? *

Yes

In the past 5 years - have you flown as a pilot, crew member or student, or planning to do so in the next 12 months?

Yes

In the last 5 years - did you participate in Motor-Powered Racing; Cave Exploration; Skin/Scuba Diving; Boxing; Mountain/Rock/Ice Climbing; Bungee Jumping; Rodeo; Hot Air Ballooning; Professional, Semi-Professional or Club Sports; Skydiving/Parachuting/BASE Jumping/ Hang Gliding - or plan to do so in the next 12 months? *

Yes

During the past 12 months did you have a change in weight of more than 10 pounds? *

Yes

In the last 5 years, have you had a life, health or hospital expense insurance application postponed, rated up or declined; had a condition excluded; or had insurance renewal or reinstatement refused? *

Yes

In the last 5 years - have you filed for disability, received benefit payments for accident or sickness, or applied to any government or insurance organization for such benefits?

Yes

In the last 5 years - had your driver’s license suspended or revoked, been convicted of or entered a plea of “guilty” or “no contest” to driving under influence (DUI/DWI), or pled guilty or convicted of moving violations? *

Yes

In the last 5 years - have you been convicted of a felony? *

Yes

Are you currently on probation? *

Yes

Have you ever filed for bankruptcy? *

Yes

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