Note:It is very important that you do your very best to provide accurate information. The more accurate the information is the more accurate our proposal will be. This form cannot be processed unless the fields marked with an * are filled in.

* Name of Proposed Insured	* Street Address	* City	* State of Residence
* Zip Code	* Daytime Phone	* Evening Phone	* E-mail Address
* Date of Birth	* Do you smoke? (Yes or No)	* What is your gender?	* Height/Weight

Amount of coverage desired:

Type of product that you are interested in:
Whole Life Universal Life Term - 5 Year Term - 10 Year Term - 15 Year Term - 20 Year Disability Long Term Care Annuities Other

Drug Abuse Related Questions

How long has the client abstained from drug use?

Did the proposed insured participate in a rehabilitation program? Inpatient or outpatient? For how long?

What types of drugs were used?

How often were the drug used?

What was the dosage or amount used?

Are there any other medical problems?

Has the proposed insured ever been treated for alcohol? If so, when and provide details?

Has the proposed insured ever been treated for an overdose? If so, when and provide details?

What are the proposed insured's exercise habits?

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Family History

	AGE, IF LIVING	STATE OF HEALTH, OR CAUSE OF DEATH	AGE AT DEATH
Father
Mother
Brother(s)
Sister(s)

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*NOTE* - Submission of this form is neither an application for insurance coverage nor a guarantee of insurance coverage.

Thank you.