Insurance Life Intake Application

INSURANCE LIFE INTAKE APPLICATION

Applicant / Insured Information

Date of Birth:    Place of Birth:    SSN / Tax ID:

Policy Details

Desired Policy Type: Term Whole Universal Variable

Desired Effective Date:    Premium Amount:    Premium Frequency:

Coverage Options and Riders

Select desired riders and options: Accelerated Death Benefit Waiver of Premium Accidental Death Benefit Child Term Rider Long-Term Care Rider Other (describe below)

Health & Lifestyle Information

Height:    Weight:    Tobacco Use: Current Former Never

Date of last medical exam:    Primary Physician:    Physician Phone:

Have you been denied, postponed, rated, or had coverage modified by any insurer in the past 5 years? Yes No

Family Medical History

Exclusions and Important Notices

The policy applied for may contain exclusions, limitations, waiting periods, and contestability provisions. Typical exclusions include death resulting from suicide within the contestable period, death resulting from the insured's commission of a felony or participation in an illegal activity, and losses arising from war or acts of war. Coverage is also subject to complete and accurate disclosure of health and lifestyle information. Material misrepresentation or fraud may render the policy voidable or claims payable denied.

Beneficiary Designation

Primary Beneficiary 1

Primary Beneficiary 2 (optional)

Documentation Checklist

Please indicate documents submitted with this intake: Copy of government-issued ID Proof of income (tax return, paystubs) Copy of prior insurance policies Signed medical records authorization Recent lab / diagnostic test results

Authorization and Certification

I certify that the information provided in this application is true, complete, and correctly recorded to the best of my knowledge. I understand that any material misrepresentation or omission may be the basis for denial of coverage or rescission of the policy. I authorize any physician, medical practitioner, hospital, clinic, medical facility, insurance company, employer, or other entity having information or records concerning me to release such information to the insurer, its representatives, reinsurers, medical information bureaus, and any consumer reporting agency for the purpose of underwriting, claim handling, or other insurance purposes. A photographic or faxed copy of this authorization shall be as valid as the original.

I acknowledge that the insurer may request additional evidence to determine insurability, which may include medical examinations, laboratory testing, and an investigation into my personal, employment, or financial records. I understand that coverage is not effective until accepted and issued by the insurer and any required initial premium is paid in accordance with the insurer's rules and the terms of the policy.

WARNING: Any person who knowingly presents false information in an application for insurance or who presents a false claim may be guilty of a criminal offense and subject to civil penalties, depending on applicable law.

By signing below, I declare under penalty of perjury that the foregoing statements and answers are complete and true to the best of my knowledge and belief.

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