newtestpage1 Country Of Transaction: Practice Application? YesNo First Name: Middle Initial: Last Name Primary Address: Address 1 Address 2 City State Zip Code Is this your mailing address? YesNo Residence Phone: Mobile Phone: Email: Gender: MaleFemale Date of Birth: Marital Status: MarriedDivorcedLegally SeparatedSingle-Not Married Have you lived in the US all your life? YesNo Do you have a driver’s license? YesNo Are you employed? YesNo Gross Mo. Earnings Policy Owner Information: First Name Last Name Or Other IndividualTrustBuy-Sell AgreementBusiness Beneficiary Information: First Name Last Name Middle Initial: Allocation % Relationship to insured. **Important! A Minor Beneficiary does not have the legal capacity to provide a valid release for the proceeds of a life insurance policy, and as a result a court must appoint a financial guardian. This procedure involves additional expenses for the minor beneficiary and may delay the payment of proceeds. Please consult with your estate or tax advisor about other ways to give the proceeds of your insurance policy to a minor. Contingent Beneficiary: First Name Last Name Middle Initial: Allocation % Relationship to insured. Medical Questions Primary Beneficiary: Height (ft.) Height(in) Weight: Has Tobacco/nicotine been used in the past 5 years? YesNo Hypertension? YesNo Stroke; diabetes; cancer; tumor; paralysis; multiple sclerosis; lupus; scleroderma; rheumatoid arthritis; muscular dystrophy; leukemia; lymphoma (Hodgkin’s and Non-Hodgkin’s); seizure; mental or nervous disorder? YesNo Any disease or disorder of the heart (excluding hypertension); liver (including hepatitis); pancreas; blood; brain; kidneys; circulatory; respiratory (including sleep apnea); gastrointestinal; neurological or nervous system? YesNo Received professional counseling or medical treatment due to the use of alcohol or drugs (including prescription drugs)? YesNo Used illegal or illegally obtained drugs (including prescription drugs); or been convicted of a drug or alcohol related charge? YesNo Pleaded guilty to or been convicted of a felony; or have any pending felony charges? YesNo Within The Past 5 years, has any person named in this application: Received disability benefits for a period of 6 months or longer or is currently receiving disability benefits (except for partial military disability or maternity)? YesNo Within The Past 3 years, has any person named in this application: Pleaded guilty to or been convicted of a DUI or DWI (driving under the influence or driving while intoxicated) or two or more moving violations? YesNo Flown as a pilot, student pilot, or crew member on any aircraft (other than commercial); or intend to do so within the next 2 years? YesNo Engaged in any recreational activity, such as: scuba diving (excluding snorkeling), mountain climbing, parachuting, hang gliding, or racing of automobiles, motorcycles, snowmobiles, or boats, or intend to do so within the next 2 years? YesNo Within the past 12 months, has any person named in this application: Been hospitalized for any reason for more than 24 hours other than childbirth? YesNo Except for testes related to Human Immunodeficiency Virus (AIDS Virus), received medical testing with results not yet reported? YesNo Except for tests related to Human Immunodeficiency Virus (AIDS Virus), been advised to receive medical testing, or treatment that has not yet been completed? YesNo Have any plans within the next two years to reside outside of the United States or Canada for 30 days or longer? YesNo Had a parent who died prior to age 65 as a result of cardiovascular illness or cancer? YesNo In the event of a positive HIV test result, would you like for us to submit your results to your physician? YesNo Do any of the persons applying for coverage have existing life insurance or annuities in force? YesNo Do you want the “Important Notice: Replacement of Life Insurance or Annuities” read aloud to you? YesNo Will replacement of existing insurance or annuity on any proposed insured occur? YesNo
