The following are the questions that will be asked and required during the application process. It is important to answer all of them honestly for the most accurate quote and best policy options for your situation.
Applicant Information:
Legal First, Middle, Last Name:
Date of Birth:
Male or Female
Address, City, State, Zip:
Phone Number:
What is the policy owner's relationship to the insured? (Self, Spouse, Brother, Daughter, etc.)
What state is the owner currently in?
Medical History:
Are you currently hospitalized or in a nursing home facility? Y/N
Have you been hospitalized 2 or more times in the last 10 years? Y/N
In the last 5 years have you been hospitalized 2 or more times? Y/N
Have you ever been diagnosed with cancer or have you had a stroke? Y/N
If Yes, in the last 2 years have you been cancer and stroke free? Y/N
If Yes, in the last 5 years have you been cancer and stroke free? Y/N
If Yes, in the last 10 years have you been cancer and stroke free? Y/N
Do you use any form of Tobacco or Nicotine? Y/N
In the past 10 years have you used any form of tobacco or nicotine products or had a blood pressure reading over 135/85? Y/N
If Yes, in the past 5 years have you used any form of tobacco or nicotine products? Y/N
If Yes, in the past 12 months have you used any form of tobacco or nicotine products? Y/N
Insureds Height in feet and inches:
Insureds Weight in pounds:
List all your prescription medications and what condition they are treating.
*We will run a script check to verify prescriptions. Please be thorough so we can provide the most accurate quote.
At this point we can go over your specific qualifying coverage options and price based on your answers above.
Ready to finalize your policy?
I will have a few more questions and will gather your signature and payment at the end.
Beneficiary 1: The person who will be in charge of your funeral arrangements:
Beneficiary 2: Additional or alternate person in charge in case Beneficiary 1 is unable or unwilling to take charge of the arrangements:
Charitable Benefit Rider (Pays out to your selected charity first in the amount you designate) Optional
Child Rider available for children ages 30 days to 18 yrs. Optional
We offer Automatic Premium Loan Provision.
After your policy has accumulated enough cash value to make a monthly premium payment, from that point on, if you miss a payment, the cash value would automatically make the premium payment.
Will this policy replace another policy? Y/N
If Yes, Name of current company: Are you using funds from that policy to pay the premium of your new policy? Y/N
If Yes, current policy number
The Script Check will be done at this point.