Term Life Application

 

The information on this application is used for the sole purpose of assisting you in obtaining life insurance.  Once we receive your information, this digital form is deleted. We adhere to all (HIPAA) Privacy Rules as directed by the government. HIPAA law summary
( If you want your term life insurance application mailed to you, Click here)


Personal Information

First Name Middle Initial Last Name

Sex   Male   Female

Date of Birth (mm/dd/yyyy)

State of Birth

Social Security Number (xxx-xx-xxxx)

Home Address (Number, Street, State, and Zip Code) How Long At Address?

Drivers License Number/State

Marital Status Married Single Divorced Widowed

Home Phone Number Work Number Extension

Email Address (Primary method of communication)

Occupation Employer Name and Address

Life insurance company of choice (optional)


Beneficiary

Primary Beneficiary (Full Name & Address)        %Share Relation SSN# Date of Birth

Primary Beneficiary (Full Name & Address)       %Share Relation SSN# Date of Birth

Contingent Beneficiary (Full Name & Address) %Share Relation SSN# Date of Birth

Contingent Beneficiary (Full Name & Address) %Share Relation SSN# Date of Birth

Amount of Insurance $ Length of Term Payment Method

Is this policy replace intended to replace any existing insurance or annuity?    Yes     No    If "YES" explain



Medical Information

In the past 10 years, have you had, been treated for, or been medically advised to be treated for, any of the following?
1) Alcoholism or Drug Use Yes No 24) Lupus / Scleroderma Yes No
2) Angina Yes No 25) Mental Illness Yes No
3) Asthma Yes No 26) Muscular Dystrophy Yes No
4) Blood Disorder Yes No 27) Neurological Disorder Yes No
5) Bronchitis Yes No 28) Palpitations / Arrhythmia Yes No
6) Cancer Yes No 29) Pancreatitis Yes No

7) Chest Pain

 Yes No 30) Paralysis Yes No
8) Cirrhosis Yes No 31) Peripheral Vascular Disease Yes No
9) Clotting Disorder Yes No 32) Pituitary Disorder Yes No
10) Colitis / Ileitis Yes No 33) Prostate Disorder Yes No
11) Coughing up of Blood Yes No 34) Rheumatoid Arthritis Yes No
12) Chronic Lung Disorder Yes No 35) Seizures / Convulsions Yes No
13) Depression Yes No 35) Shortness of Breath Yes No
14) Diabetes Yes No 37) Skin Disorder Yes No
15) Dizziness / Fainting Yes No 38) Sleep Apnea Yes No
16) Gastrointestinal Bleeding Yes No 39) Stroke Yes No
17) Headaches Yes No 40) Blood in Urine Yes No
18) Heart Attack Yes No 41) Sugar, Protein in Urine Yes No
19) Heart Murmur Yes No 42) Suicide Attempt Yes No
20) Hepatitis Yes No 43) Thyroid Disorder Yes No
21) High Blood Pressure Yes No 44) Tuberculosis Yes No
22) HIV Infection Yes No 45) Tumor, Mass or Lump Yes No
23) Kidney Disorder Yes No 46) Ulcer / Gastritis Yes No

 

For reasons other than above, in the past 5 years have you:
 
47) consulted with or received treatment form a care provider or treatment facility? Yes No
48) had an EKG, X-ray, or other diagnostic test? Yes No
49) been advised to have any diagnostic test, hospitalization or surgery that was not completed? Yes No
50) had medication prescribed for a physical or mental disorder? Yes No
   
51) In the past 6 months, has your weight changed more that 15 pounds? Yes No
   
52) Other than as prescribed by a physician, have you ever used marijuana, narcotics, stimulants, sedative, hallucinogens, or any prescription drugs? Yes No
If "yes" give name, form, amount, and length of use, and date last used in DETAILS section.  
 
53) Do you drink alcohol currently? Yes No
If so, how often do you drink alcoholic beverages? Occasionally 3 or less days weekly 4 or more days weekly
54) When you drink, how many drinks do you consume per day 3 or less drinks 4-6 drinks 7 or more drinks
55) Do you use tobacco products? Yes No
56) Is there a history of diabetes, cancer, hypertension, heart or kidney
disease in your family?		 Yes No
If so, list the details as to who, what, and at what age.
Height Weight lbs.
 

Details (For explanations and requested information. Identify question number being addressed)
State condition and give diagnosis, dates, durations, treatments, tests, medications prescribed and names and addresses of all care providers and treatment facilities.

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