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Referred by:

SECURE FORM

INSURED - First name *

Middle name

Last name *

Beneficiary 1. *

Relationship *

DOB - beneficiary *

Percent (%)

Beneficiary 2. / Contingent

Relationship

DOB - contingent

Percent (%)

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

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

Home address *

City *

State *

Zip *

INSURED information:

Gender at birth *

Female

Male

Tobacco / nicotine use *

Yes

Date of birth *

Insured's EMAIL *

Phone (MOBILE) *

Home or secondary #

Height (ft) *

inches *

Weight *

SSN *

Marital status *

Driver license/ID number *

DL/ID issued state *

Place of birth (State, city) *

US citizenship

US citizen

legal US resident

Employment status *

Employed

Homemaker

Unemployed

Disabled

Retired

Do you have any existing coverage? *

Yes

Will this insurance replace other policy? *

Yes

List your MEDICATIONS (Rx only), reason, when diagnosed. *

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:

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 any of the following (other than for fractures, bone or joint surgery, including replacement): wheelchair, electric scooter, or oxygen equipment to assist breathing (excluding use for sleep apnea)?

1.d) None of the above.

Q1- details: what condition, when diagnosed, current status. *

Q2. Have you EVER been: *

2.a) Diagnosed as having Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or Human Immunodeficiency Virus (HIV) Infection (symptomatic or asymptomatic) or been treated for AIDS, ARC, or HIV by a physician or health care provider?

2.b) Diagnosed with, been treated for or advised by a physician or health care provider to receive treatment for Alzheimer’s Disease, 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 by a physician or health care provider 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: what condition, when diagnosed, current status. *

Q3. In the LAST 12 MONTHS, have you been: *

3.a) Advised by a physician to have a surgical operation, diagnostic testing other than for routine screening purposes or for those related to HIV/AIDS, treatment, hospitalization, or other procedure which has not been done or for which results are not known?

3.b) Diagnosed by a physician or health care provider as having heart disease or heart surgery of any kind?

3.c) In the past 2 years, has the Proposed Insured been diagnosed with, been treated for or advised by a physician or health care provider to receive treatment for any form of cancer (except basal or squamous cell skin cancer)?

3.d) None of the above.

Q3- details: what condition, when diagnosed, current status. *

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, including Chronic Obstructive Pulmonary Disease (COPD), Chronic Bronchitis, Emphysema, or Sarcoidosis?

4.d) None of the above.

Q4- details: what condition, when diagnosed, current status. *

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: what condition, when diagnosed, current status. *

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, or Valvular Heart Disease with surgical repair or replacement?

6.b) Stroke or Transient Ischemic Attack (TIA)?

6.c) None of the above.

Q6- details: what condition, when diagnosed, current status. *

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

Benefit amount requested: *

Monthly premium expected (approx) *

Coverage period

Is someone OTHER than the insured paying the premium? *

Yes

Financial institution name *

Account holder NAME *

Routing number *

Account number *

Day of the month for recurring payments *

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.

comments

Submitter:

Type your FULL NAME (as on your ID) *

Phone# *

Email *