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Applying for Life Insurance:

The Application Process

To apply, either call us at 1-800-722-9053 or request an emailed application or start with this form:

All entries are encrypted and secure. Please be available by telephone to expedite the rest of the process.

Start Application Process

$amount of coverage:
Name of the policy:
Coverage period:
Premium quoted:
Payment Method:
Payment Frequency:

Primary beneficiaries-Relationship to you:
Contingent beneficiaries-Relationship to you:

2. Yes No

a. do you have any other life insurance in force or pending approval?  If yes, state:

a.(i) company, amount, month/year issued:
a.(ii) company, amount, month/year issued:
a.(iii) company, amount, month/year issued:
b. your occupation(s):
c. annual gross income:

 Yes No

d. are you a U.S. citizen or a permanent resident (Green Card status)?

e. if this policy is issued, will any current life insurance or annuity be terminated?

f. if so, which companies:
g. current employer - name and address:
h. how long with employer:
i. state/country of birth:


feet  inches

Ever used
Yes  No
Tobacco last use: date, type,
  & number of years used:
Date of last visit to a doctor, chiropractor, or therapist or put 'none':
Reason for visit:
Weight gain in last year, put reason, or 'none':
Name, address, and phone number of practitioner:
Tests done, findings, remaining effects:
Weight loss in last year, put reason, or 'none':

4. Has you ever: Yes No

a. had insurance rescinded, charged extra, declined, postponed, or ridered?

b. been convicted of a felony?

c. been treated or evaluated for alcoholism, often used alcohol to excess, or advised to reduce its consumption?

d. been evaluated/treated for substance abuse/dependency, or used illegal or controlled substances, e.g. marijuana, cocaine, IV drugs, meth, sedatives?

e. had surgery/treatment/testing recommended but not yet completed?

f. have fixation/prosthetic devices present, e.g. plates, pins, implants (including breast), screws, pacemakers, valve replacements, transplants?

g. received disability benefits or is currently disabled?

h. on current active status in the Armed Forces or expect soon to be?

i. resided outside U.S. in last 3 years or planning to travel outside U.S./Canada?

j. been convicted of drunk driving?

k. date(s) of conviction, in which state:

Have you ever:   Yes No

l. in the last 10 years been in a hospital or medical facility for treatment, confinement or observation?

m. last 10 years had abnormal physical exam or abnormal test results?

n. in the last 5 years done scuba diving, skydiving, rock climbing, racing, or other hazardous activity or planning any?

o. in the past 5 years flown, or plan to fly, as a pilot or crew member?

p. in the last 5 years had a driver's license suspended or revoked?

q. been diagnosed/treated for AIDS/ARC or for any immune system disorder, or tested positive for HIV antibodies?

r. been a candidate or recipient for an organ, bone marrow, or stem cell transplant or volunteered as a donor?

s. in the last 2 years been advised to take or taken prescription medications?

t. in the last 12 months, consumed any alcoholic beverages?

u. alcohol consumption: type, amount, frequency:

v. Details for "yes" answers in 4. above (include names of countries for h.):

5. In the last 10 years have you had any indication, diagnosis, or treatment for:

q. Does anyone in this application have any mental or physical impairment, handicap, retardation, disease, or deformity or been examined or treated by any medical practitioner for any reason than disclosed above?

r. Has any member of your family had diabetes, cancer, heart disease, Huntington's Disease, or polycystic kidney disease?

s. Did any parent or sibling of yours die prior to age 60 due to heart disease?

t. Details for "yes" answers in 5. above:  Question #,  name of condition,  start and end date of treatment or if still present,  treatment/prescriptions and dosage.

6. Female Applicants:

a. date of last pap smear, results/follow-up or 'none':
b. if more than 40 days since the last menstrual period, explain reason:
c. Name, address, phone number of physician(s) or enter 'none':
d. any abnormal pap smear results?:
Yes   No

e. abnormal pap results: who, date, condition, if ended, % recovery, & date of last normal result:

f. Currently pregnant?
Yes  No
g. Ever had a miscarriage or
complications of pregnancy?
Yes  No
h. Details for "yes" answers in g.

All information submitted is under the control of, and supervision by, the insurance licensee. The information is submitted only to the insurance company you name above in accordance with Federal privacy laws and state insurance law and regulation. So that any further requirements can be quickly handled, please be available by telephone.

All entries are transmitted securely.

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Do not terminate current life insurance coverage or turn down guaranteed entitlements like COBRA or State continuation which may include life insurance coverage until you receive written confirmation of approval from the insurance company you are applying to. When you receive the insurance contract, which may be called a policy or certificate, you should be sure that you understand and agree with its terms and conditions. You should check the effective date and understand and agree with the coverage offered, and what the premium is.

Rates that have been quoted are not necessarily the rates that all applicants may get and may not be the actual rate that you are offered. Differences may be caused by the insurer's determination of your risk category and any optional benefits that may have been selected. The life insurance company alone will determine the final rate for any applicant according to its underwriting rules.

Rates quoted are also only for the effective date specified. If the actual effective date is different, then the premium may be different for that reason. The premium as of the effective date may or may not be guaranteed for a period of time after the effective date depending on the terms of the insurance contract.

Completion and submission of this form does not complete an application. No life insurance application will be processed and no life insurance coverage will be issued unless you are available to complete all the necessary steps of the application.