Insurance Quote

Client Information
Doctor's Information
Product Information
Underwriting Information
Beneficiary Information

Primary Proposed Insured, Cont.

Driver's license?
Personal Earned Income means monies received for work performed.
Employment Information
If Primary Proposed Insured is not self-supporting or is a child under age 18, what amount of insurance is in force and/or pending on:
Existing Insurance
Background Information
 
Primary Insured


Do any of the Proposed Insureds intend to travel or reside outside of the United States or Canada within the next two years?

In the past five years, have any of the Proposed Insureds flown as a pilot, student pilot or crew member of any aircraft, or have any intention to do so in the next two years?

In the past five years, have any of the Proposed Insureds engaged in motor sports events or racing (auto, truck, motorcycle, boat, etc.); rock or mountain climbing; skin or scuba diving; aeronautics (hang-gliding, sky diving, parachuting, ultra light, soaring, ballooning,) or have any intention to do so in the next two years?

Have any of the Proposed Insureds ever had an application for insurance modified, rated, declined, postponed or withdrawn?

Have any of the Proposed Insureds ever filed for bankruptcy, or have the intention to seek bankruptcy protection within the next 12 months?

In the past five years, have any of the Proposed Insureds pled guilty or been convicted of any driving violations to include driving under the influence of alcohol or drugs?

Have any of the Proposed Insureds ever been convicted of, or currently charged with, a felony or misdemeanor?

Are any of the Proposed Insureds an active duty service member of the U.S. Armed Forces?

Is there an intention that any party, other than the listed Owner or Beneficiary, will obtain any right, title, or interest in any policy issued on the life of any of the Proposed Insureds as a result of this application?

Does the Owner or any of the Proposed Insureds intend to finance any of the premium required to pay for this policy through a financing or loan agreement?

Is the Owner, any of the Proposed Insureds, or any person or entity, being paid (cash, services, etc.) as an incentive to enter into this transaction?

Has the Primary Proposed Insured and/or Other Proposed Insured ever used any form of tobacco or nicotine products?
Payment Information

Has any Proposed Insured ever been diagnosed with, or sought treatment from a member of the medical profession for any of the following: a heart attack; stroke; coronary artery disease or other heart disease; cancer; diabetes; or disorder of the immune system, including but not limited to Acquired Immune Deficiency Syndrome (AIDS) or infection by the Human Immunodeficiency Virus (HIV)?

Has any Proposed Insured, during the last two years: (1) been confined in a hospital or other health care facility (except for childbirth without complications); (2) received medical treatment or counseling for alcohol or drug use; or (3) been advised to have any diagnostic test or surgery not yet performed (except for those tests related to the Human Immunodeficiency Virus (HIV))?

Is any Proposed Insured either less than 14 days old or over age 70 1/2?