Life Application

Life Application

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

Beneficiary

Primary 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.

Condition #4

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