Application for FINAL EXPENSE WHOLE LIFE

SECURE FORM

READY TO START COVERAGE ?
Complete the APPLICATION below

Coverage starts after underwriting approval. You will receive a policy if approved. A telephone call with the Underwriter may be necessary before approval.


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.

Name a BENEFICIARY

* If you have more beneficiaries, please use the comment box below.

Where should we mail the policy? (no P.O. boxes)

INSURED information:

Primary physician information

Medical questions - INSURED

(any "Yes" answers will NOT disqualify you from being approved, but in some cases you may qualify for Guaranteed Issue Whole Life instead if you have any MAJOR health issues. Guaranteed Issue plans may have higher rates).

Check all that apply:

Premium payment information

Additional info, comments:

Feel free to ask a question or leave a comment. Use this field for additional beneficiaries, list additional health issues, diagnosis, pre-screening questions.


Signature: