Insurance Life Proposal

INSURANCE LIFE PROPOSAL

Applicant / Insured Information

Date of Birth:    Gender:

Phone:    Email:

Proposed Policy Details

Proposed Policy Type: Term Life Whole Life Universal Life

Premium Amount (annual):    Payment Mode: Annual Monthly Quarterly

Proposed Policy Effective Date:    Policy Term (if applicable):

Coverage Options & Riders

Accidental Death Benefit Rider
Waiver of Premium Rider
Child Term Rider
Disability Income Rider

Exclusions, Limitations, and Acknowledgments

The insurer may limit or exclude coverage for acts such as suicide within the contestable period, acts of war, participation in criminal activity, or material misrepresentation in this proposal. The proposed insured acknowledges that coverage will be subject to the policy terms, including any contestability and suicide provisions described in the issued policy.

I acknowledge that I have read and understand the general exclusions and limitations that may apply to the policy and riders requested.

Medical & Underwriting Questions

1. In the past 5 years, have you been diagnosed with, treated for, or had symptoms of any heart disease, stroke, cancer, diabetes, or kidney disease? Yes No

2. Do you use tobacco, nicotine products, or have you used them within the last 12 months? Yes No

3. Have you had any motor vehicle convictions, DUI, or license suspensions in the past 5 years? Yes No

Beneficiary Designation

Primary Beneficiary 1

Relationship:    Share:

Primary Beneficiary 2 (optional)

Relationship:    Share:

Contingent Beneficiary (optional)

Relationship:    Share:

Documentation & Checklist

Please indicate which documents are attached or will be provided with this proposal:

Photo ID / Government ID
Proof of Income / Paystubs
Relevant Medical Records / Reports
Previous Insurance Policies

Declarations and Authorization

I, the undersigned applicant and proposed insured, represent and warrant that the statements and particulars contained in this proposal are true, complete, and correctly recorded to the best of my knowledge and belief. I understand that this proposal, together with any medical examinations, statements, and supplemental applications, will form the basis of any policy issued. I authorize any licensed physician, medical practitioner, hospital, clinic, or other medical or medically related facility, consumer reporting agency, or insurer to release to the insurer or its authorized representatives any medical, financial, or other information necessary to evaluate this application for insurance.

I understand that the insurer may require additional evidence of insurability and may defer, accept, modify, or decline the risk. I further understand that material misrepresentation or omission may render the policy voidable, and that the insurer has the right to contest the validity of coverage during the contestable period as set forth in the policy. I authorize the use of electronic signatures and attest that I am authorized to provide the information above.

By signing below I certify under penalty of perjury that the information provided in this proposal is true and complete. I acknowledge that acceptance of any premium payment by the insurer does not constitute acceptance of the risk.

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