Client Application

Owner Information
Is the Owner the same as the Insured?*
- Yes
- No
Owner Name*
First Last
Owner's Date of Birth*
Month
Day
Year
Social Security Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Mobile Phone*
Work Phone
Email Address*
Do you have a Driver's License?*
- Yes
- No
Driver's License #*
What is your relationship to the insured?*
License State*
State
Are you a U.S. Citizen?*
- Yes
- No
Purpose of Insurance*
- Personal
- Business

Existing Insurance
Do you have any existing or pending life insurance or annuities?*
- No
- Yes
Details about your current policy:
Name of the Carrier*
Amount*
Policy Number
Year Issued
Beneficiary
Are you replacing this policy?*
- No
- Yes
Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your exist policy or contract?*
- No
- Yes
Are you considering using funds from your existing policies or contracts to pay premiums due to the new policy or contract?*
- No
- Yes
- Third Choice
Reason for replacement:*
Total amount of accidental death Insurance inforce with all companies?

Health Information
Have you ever been told you have high blood pressure (hypertension)?*
- No
- Yes
Do you currently take medication or have any history or treatment for high blood pressure?
- Yes
- No
What was your usual blood pressure reading for the past 6 months?
Select the option that best describes your blood pressure over the past 12 months:
- Very well-controlled
- Reasonably well-controlled
- Not well-controlled
Have you ever been diagnosed with, or received treatment/advice for, any of the following?*
AIDS, ARC, HIV positive | Emphysema/COPD | Liver Failure | Alcoholism | Epilepsy/Seizure Lupus |ALS (Lou Gehrig's Disease) | Gastric Bypass/Lap Band | Melanoma | Atrial Fibrillation Heart Attack |Multiple Sclerosis (MS) Barrett's | Esophagus Heart Disease | Parkinson's Disease | Bipolar Disease | Heart Failure | Peripheral Artery (PAD)/Vascular Disease (PVD) | Cancer (except certain skin cancers) | Heart Valve Replacement | Rheumatoid Arthritis (RA) Chron's Disease | Hepatitis B | Sleep Apnea | Diabetes | Hepatitis C (active) | Stroke/Transient Ischemic Attack (TIA) | Drug Abuse | Kidney Disease Ulcerative Colitis (UCI)
- No
- Yes
Which one?*

Additional Information
Have you had more than 3 speeding tickets and/or moving violations in the past 3 years; or had a DUI, license suspension, or revocation in the past 5 years.*
- Yes
- No
Have you used marijuana in the last 5 years?*
- Yes
- No
Have you ever had an application for life or health insurance declined, postponed, modified, or rated or offered other than as applied for?*
- Yes
- No

CLIENT APPLICATION