Application for Life Insurance

Policy Owner Information

Please type in ALL CAPS
Owner's Legal Name

First NameLast Name
Title
Mr., Mrs., Ms.
Owner's First Name*
First Name
Middle Name - Optional
If you have 2 middle names - only 1 will be allowed
Last Name*
Last Name
Suffix
Sr., Jr., II, III, IV, etc
Residential Address (No P.O. Boxes)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Proposed Insured*
SSN / TIN*
Date of Birth*

MonthDayYear
Date
Phone Number*
Email Address (owner & proposed insured must have different emails if both are over 18 years old)*
example@example.com
Citizenship*

U.S. CitizenPermanent Resident Alien (select country below)Other - Visa Holder (select country below)
Country of Perm. Resident
Country of Visa Holder
Date Entered US

MonthDayYear
Date
Visa Expiration Date

MonthDayYear
Date
Identification Type*
DL/ID/Passport Number*
State of Driver's License/State ID *
DL/ID/Passport Expiration Date*

MonthDayYear
Date
Employment Type*

EmployedUnemployedRetired
Employer Name*
Employer Address*

Street Address

Street Address Line 2

CityState

Zip Code
Occupation*
Annual Income*
How Long Employed or Retired?*
In Years
Is there a Contingent Owner?*

Contingent Owner Information

Option available, if Proposed Insured and Owner are NOT the same person.
Contingent Owner's Full Legal Name

PrefixFirst NameLast NameSuffix
Title
Mr., Mrs., Ms.
Owner's First Name*
First Name
Middle Name - Optional
If you have 2 middle names - only 1 will be allowed
Last Name*
Last Name
Suffix
Sr., Jr., II, III, IV, etc
Residential Address*

Street Address

Apt/Unit/Suite

CityState

Zip Code
Relationship to Owner*
SSN / TIN*
Date of Birth*

MonthDayYear
Date
Phone Number*
Email Address (Some providers require contingent owners to sign application)*
example@example.com

Primary Beneficiary (total share % must equal 100%)

Contingent Beneficiary (total share % must equal 100%)

Existing Policies & Annuities
Does the proposed insured have any existing, pending OR lapsed/cancelled life insurance or annuities?*

NoYes

Primary Physician Information

For Proposed Insured
Doctor's Full Name (If you don't have a specific doctor, put hospital/clinic name)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date Last Visit (approx. date & year is okay)

MonthDayYear
Date
Reason/Results?
example: Annual Exam / Normal
Height*
example: 5'10
Weight*
Any Medical Conditions or Prescriptions/Medication in last 5 years:*
Diagnosis, date first diagnosed, medication name, etc.
Any ER visits or hospitalizations in last 5 years due to medical conditions? *
List approx. dates and length of hospitalization
Any surgical procedures in the last 5 years? Please list month & year, reason/cause, medication(s), and if still recovering or fully recovered.
Please be as detailed as possible.

Children's Doctor Name, Address, Phone Number
Certain providers require the child's doctor information for the Child Benefit Rider

Premium & Banking Information

Prepaid accounts are not acceptable.
Name of Banking Institution *
Account Type*
Account Number*
Routing Number*
Draft Day (1st - 27th)*
Is the Payor the same as Owner?*
Payor's Full Name*

First NameLast Name
Address

Street Address

Apt/Unit/Suite

CityState

Zip Code
Phone Number*
Email Address*
example@example.com
Permission to Draft Initial Premium

At Underwriting ApprovalWait until approval is discussed with client

Other Requirement Information

Some providers require the following questions
Are you currently in the armed forces or intend to become a member? (if yes, give full details if any deployment orders outside the U.S.)*

NoYes - EnlistedYes - OfficerYes - Reserves
Have you filed or have a pending bankruptcy in the last 12 months?*

NoYes - provide full details including Chapter 7, 11, or 13, date filed, date of discharge and dismissal, if any.
Have you ever been convicted of a felony, misdemeanor or infraction other than a traffic violation?*

NoYes - provide full details including state, offense & date of offense
Additional Comments
Should be Empty:

	Full Legal Name	Age	Amount of Total Life Insurance
Father
Mother
Sibling
Sibling
Sibling
Sibling

	Current Age	If deceased, Age at Death	Cause of Death	History of Heart Disease, Heart Attack or Stroke? (if yes, list age of onset and medical condition)	History of Cancer? (if yes, list age of onset and type of medical condition)
Father:
Mother:
Brother #1:
Brother #2:
Brother #3:
Brother #4
Sister #1
Sister #2
Sister #3
Sister #4

Agent Disclosure Section