Agent Name*
Address
City
State
Zip
Email*
Phone*
Fax
Broker/Dealer
Return Method
FaxMailBroker pick-upEmail
Name*
Date of Birth*
Gender*
MaleFemale
Health Class*
—Please choose an option—Super PreferredPreferredStandard PlusStandard
Cigarettes*
YesNo
If no, has use been discontinued?
If yes, for how long?
—Please choose an option—1 year2 years3 years4 years5 years
Alternate Tobacco*
—Please choose an option—NoPipeCigarChewing TobaccoNicotine GumNicotine PatchE-Cigarette
Marijuana*
If yes, recreational or medical use?
RecreationalMedical
If medical usage, describe medical condition
Describe usage amounts per week
Cardiovascular or cancer death in parent or sibling prior to age 60
If yes, provide details
Blood pressure treatment?*
Blood Pressure Reading*
Cholesterol treatment?*
Cholesterol level*
—Please choose an option—300+250-299200-249150-199100-149<100
Cholesterol/HDL ratio*
—Please choose an option—8.0 +7.5 – 8.07.0 – 7.56.5 – 7.06.0 – 6.55.5 – 6.05.0 – 5.54.5 – 4.0
Cancer?*
Coronary/Diabetes?*
Alcohol/drug treatment?*
Other Impairments?*
Number of moving/driving violations in the past 3 years*
—Please choose an option—012345
Reckless driving/DUI suspension/revocation*
Please provide details
—Please choose an option—None in the past 5 yearsNone in the past 3 yearsNone in the past 2 years
Private Aviation*
If yes, secure and complete aviation questionnaire
Commercial Aviation*
Hazardous activities*
Occupation*
If hazardous, provide details
US Citizen?*
If no, provide details
Bankruptcy*
Height*
feet
inches
Weight*
pounds
Primary Objective
Death BenefitCash AccumulationGuaranteesLow PremiumFinal ExpenseLife + LTC
Face Amount(s)
Specified Carrier
Product Type
Universal LifeWhole LifeWhole Life Blend% TermVariableSurvivorshipOther
If Other, please specify
Level
-Pay
To Age
1035 Rollover
Other Dump-In
Endow
Alternative Amount at Maturity or Age
Interest/Div Rate
Current or Other
%
AnnualSemi-AnnualQuarterlyMonthly
State of Issue
—Please choose an option—AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
State in which insurance is to be used
Term Rider – Insured Amount: To Age
Term Rider – Other
Name
Date of Birth
Amount
Waiver of Premium
Child Insurance Rider
ADB
Other
Mail, phone and fax, if other than Agent Information
Additional Information
Appointment FormsApplication PacksProduct Information
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