admin-app Name Referred by: SECURE FORM Insured: , age . Smoke? You're applying for - BENEFIT: $, expected premium $ mo. [click to EDIT amount or age/gender] INSURED First name Middle Initial Last name Date of birth PRIMARY Beneficiary Relationship DOB - beneficiary Add more beneficiaries? Yes No Mailing address (no P.O.Box) City State - Select State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Does the INSURED reside at the same address above? Yes No INSURED information: Gender female male Have you used tobacco or nicotine in the last 12 months? no yes Insured's EMAIL Phone (MOBILE) Home or secondary # Height (ft) Height (ft) 3 ft. 4 ft. 5 ft. 6 ft 7 ft inches inches 0 in. 1 in. 2 in. 3 in. 4 in. 5 in. 6 in. 7 in. 8 in. 9 in. 10 in. 11 in. Weight SSN of insured Driver license/ID number DL/ID issued state - Select State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Marital status Marital status Married Single Divorced Separated Widowed Civil union Domestic partner Place of birth (City, State) US citizenship US citizen legal US resident Employment status Employed Homemaker Unemployed Disabled Retired Do you have any existing coverage? No Yes Will this insurance replace other policy? No Yes List your MEDICATIONS, reason, when diagnosed NO MEDICAL EXAMS! Just answer a few health history questions. Medical questions - INSURED (any "Yes" answers will NOT disqualify you from being approved!). Check all that apply: Q1. Are you (the person to be INSURED) currently: 1.a) Bedridden or confined to any hospital, nursing home, long-term care facility or skilled nursing facility; or receiving or been advised to receive care in a nursing home, hospice care, or home health care? 1.b) Requiring assistance with activities of daily living such as taking medications, bathing, dressing, eating, toileting, getting in and out of a chair or bed, or control of bowel or bladder problems? 1.c) Requiring a wheelchair, electric scooter, or oxygen equipment to assist breathing? 1.d) None of the above. Q1) Details: Which condition? when diagnosed? Q2. Have you EVER been: 2.a) Diagnosed with AIDS, ARC or HIV? 2.b) Diagnosed with Alzheimer’s, Dementia, Huntington’s Disease, Sickle Cell Anemia, Myelodysplastic Syndrome (MDS), Lou Gehrig’s Disease (ALS), Quadriplegia, Paraplegia, Down’s Syndrome, mental incapacity, congestive heart failure, Cirrhosis, Metastatic Cancer or recurrent Cancer of the same type? 2.c) Diagnosed with insulin shock, diabetic coma, or had an amputation due to diabetic complications or diagnosed with End Stage Renal Disease or requiring dialysis? 2.d) Advised to receive or have received an organ or bone marrow transplant? 2.e) Diagnosed as having a terminal medical condition that is expected to result in death within the next twelve 12 months? 2.f) None of the above. Q2) Details: Which condition? when diagnosed? Q3. In the LAST 12 MONTHS, have you been: 3.a) Advised to have a surgery, testing or procedure which has not been done or for which results are not known? 3.b) Diagnosed as having heart disease or heart surgery of any kind? 3.c) In the past 2 years: diagnosed, treated or advised to receive treatment for cancer (except basal or squamous cell skin cancer)? 3.d) None of the above. Q3) Details: Which condition? when diagnosed? Q4. Have you EVER received care for, or advised to seek treatment for: 4.a) Diabetes before age 50 or diabetes at any age with complications of Retinopathy (eye), Nephropathy (kidney), Neuropathy (nerve) or Peripheral Vascular Disease (PVD or PAD)? 4.b) Hepatitis C? 4.c) Chronic Lung Disease, COPD (Chronic Obstructive Pulmonary Disease), Chronic Bronchitis, Emphysema, or Sarcoidosis? 4.d) None of the above. Q4) Details: Which condition? when diagnosed? Q5. In the LAST 4 YEARS, have you been diagnosed, treated or advised to seek treatment for: 5.a) Cancer, Leukemia, Melanoma or any other internal cancer (except basal or squamous cell skin cancer)? 5.b) Chronic Kidney Disease, Systemic Lupus or Scleroderma? 5.c) Bipolar Depression, Schizophrenia, Parkinson’s Disease or Multiple Sclerosis? 5.d) None of the above. Q5) Details: Which condition? when diagnosed? Q6. In the LAST 2 YEARS, have you been treated or advised to seek treatment for: 6.a) Coronary Artery Disease, Heart Attack, Coronary Artery Bypass Surgery, Angioplasty, Cardiomyopathy, irregular heart rhythm / arrhythmia, pacemaker / defibrillator, Valvular Heart Disease with surgical repair or replacement? 6.b) Stroke or Transient Ischemic Attack (TIA)? 6.c) None of the above. Q6) Details: Which condition? when diagnosed? Q7. In the LAST 2 YEARS, have you: 7.a) Been convicted of or currently awaiting trial for a felony? 7.b) Been treated for or advised to have treatment for alcohol or drug abuse, or convicted more than once of reckless driving or driving under the influence of drugs or alcohol? 7.c) Used unlawful drugs in any form or abused or misused prescription drugs? 7.d) Been hospitalized by a physician or health care provider for any mental or nervous disorder? 7.e) None of the above. Q7) Details: Q8. In the LAST 12 MONTHS, have you: 8.a) consulted a physician for chronic cough, unexplained weight loss greater than 10 pounds, fatigue or unexplained gastrointestinal bleeding? 8.b) None of the above. Q8) Details: Premium payment information If not sure how much your expected premium will be, call (321) 300-1446 Benefit amount: Premium expected Select DATE TO START COVERAGE 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th 15th 16th 17th 18th 19th 20th 21st 22nd 23rd 24th 25th 26th 27th 28th Who will pay the premium? Insured Other Payment method Bank draft / ACH (PREFERRED) Credit card / debit card / Direct Express (NOT ALL PLANS ACCEPT CARD PAYMENT) Additional info, comments: Feel free to ask a question or leave a comment. Use this field for additional beneficiaries, list additional health issues comments Submitter: Submitter's FULL NAME * After you click SUBMIT APPLICATION above, an underwriter will review and contact you if needed to confirm any information provided on your application. After approval, a policy will be mailed to INSURED or PAYOR. Coverage starts after underwriting approval of your rate. You will receive a policy by mail. A telephone call with the Underwriter may be necessary before approval. NO MEDICAL EXAM needed for benefits up to $40,000. Over $40,000 it's possible to need physical measurements and urine sample/test, possibly a blood test needed depending on your age, benefit amount applied for and time since last Dr. visit. Customer Satisfaction Guarantee: you have 30 days to receive full refund, if the coverage does not satisfy your needs. After the first 30 days, you may cancel at any time and coverage will stop at your request. Otherwise, your coverage will last for the life of the policy and premiums will never increase during that time.