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Life & Disability

Proposed Insured (PI)

1. First Name

2. Last Name

3. Middle Name

4. Male or Female

5. DOB

6. SSN

7. Height/Weight

8. US citizen?

If No, Permanent Res. Card # (include copy)

Type of Visa (include copy)

9. Place of Birth

10.Marital Status

11. Driver License #, State

12. Residences Address

14. Employer Name and Address

15. Occupation

16. Employer Phone #

17. Years employed

18. Annual Income

19. Household Income

20. Net Worth

21. Life Insurance Pending or in-Force?

Company Name

Policy #

Year of Issue

Amount of Insurance

Replacement

1035 Exchange

22. Family History

Father: Age if living

Health Status

Age of Death

Cause

Mother: Age if living

Health Status

Age of Death

Cause

Siblings: Age if living

Health Status

Age of Death

Cause

23. User of Tobacco or Products Containing Nicotine

Type of Product

Date First Used

Plan Information

1.Plan of Insurance

3.Death Benefit Option-Increasing or Level

4.Riders/Living Benefits

5.Planned Premium

7.Premium Frequency

9.Bank Name

11.Account Number

Owner (if Other than proposed insured)

1.First Name

2.Last Name

3.Middle Name

4.SSN

5.DOB

6.Relationship to PI

7.US Citizen?

9.Residence Address

Payor (if Other, than PI or Owner)

1.First Name

2.Last Name

3.Middle Name

4.SSN

5.DOB

6.Relationship to PI

7.US Citizen?

9.Residence Address

Primary Beneficiary

1.First Name

2.Last Name

3.Middle Name

4.SSN

5.DOB

6.Relationship to PI

7.Residence Address

8.Phone #

Contingent Beneficiary

1.First Name

2.Last Name

3.Middle Name

4.SSN

5.DOB

6.Relationship to PI

7.Residence Address

8.Phone #

Physician Information/Health Summary

1.Physician Name

2.Physician Address

3.Date and Findings of Last Visit

4.Tests Performed and Treatment Received

5.Any Diagnosis(ever)

6.Any Diseases (ever)

Risk Information

1.Do you plan to fly, or have you flown during the past 2 years, as a pilot, student pilot or crew member?

2.Do you plan to participate, or have you participated within the past 2 years; in motor vehicle or boat racing, in hang gliding, sky or scuba diving, or mountain, rock or technical climbing?

3.Do you now, or do you plan to reside or travel outside of the United States or Canada within the next year?

4.Are you a member of the Military Armed Forces, Military Reserves or National Guard?

SIMPLE Issue/Health Summary

5.Have you been convicted of DUI, or reckless driving, or driving without a license, or have your license been suspended, restricted or revoked in the last ten years? If yes, provide date

6.Any history of felony? If yes, provide Date

7.Any history of bankruptcy in the last five years or are you currently involved in any bankruptcy proceedings that have not been discharged yet? If yes, provide type and date discharged

8.Is stated blood pressure less than 140/85?

9.Is total Cholesterol is less than 220, and cholesterol/HDL ratio is less than 5.0?

10.Are you currently taking any prescription medication?

11.If age 50 or greater, does applicant have primary care physician and evidence of routine physicals?

12.If a parent or a sibling died from breast, colon, ovarian or prostate cancer prior to age 60?

13.If a parent or a sibling died from cardiovascular disease, stroke or diabetes prior to age 60?

14.If ever life, health or disability insurance has been rated, ridered or declined?

15.Any prior informal request to The Principal within the last 24 months?

16.Any labs have been ordered or completed within the last 12 months for life or disability insurance?

Notes: