SECTION I
Proposed Insured
SECTION II
Owner & Beneficiary
A. Owner Information — complete only if proposed insured is not the owner or is a minor
If owner is a trust, submit a copy of the first and last page of the trust document and have the trustee sign as "Trustee" on the Signature of Owner lines.
B. Beneficiary Information
Legal restrictions apply to release of proceeds to a minor beneficiary without court authorization. Naming a minor as a beneficiary can result in legal expenses and a delay in payment. All beneficiary designations are revocable unless otherwise requested.
Type:
SECTION III
Existing Coverage & Pending Insurance
1. Is the policy applied for intended to replace any existing life insurance or annuity policies with this or any other company? If yes, complete and submit forms required by the state of application.
2. Does anyone proposed for insurance have any other life insurance or annuities in force, or is such person currently applying for any other life insurance besides this application? If yes, complete the table below.
| Insured's name | Company | Life ins. or annuity | Amount | Year issued / applying | Purpose | Replacing? |
|---|---|---|---|---|---|---|
| |
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SECTION VIII
Nonmedical History
This section must be completed if the Proposed Insured is age 18 or over.
1. Has the Proposed Insured:
(a) Applied for or received disability benefits in the last 5 years?
(b) Applied for life or health insurance that was declined, postponed, or modified, or had reinstatement of an insurance policy denied?
(c) Flown as a pilot or crew member within the last 2 years, or does the Proposed Insured intend to do so in the next two years? If yes, complete Aviation Questionnaire.
(d) Had more than 2 moving motor vehicle violations in the last 3 years?
(e) Had his or her driver's license in a state of revocation, restriction, or suspension, or had a driving while intoxicated or driving under the influence of alcohol or drugs violation in the last 5 years?
(f) Engaged in scuba diving, auto or motorcycle racing, rock or mountain climbing, ultra light flying, hang gliding, or sky diving in the last 2 years, or does the Proposed Insured intend to do so in the next two years? If yes, complete appropriate questionnaire(s).
(g) Traveled outside the United States or Canada in the last 2 years, or does the Proposed Insured intend to do so in the next 2 years? If yes, complete Foreign Travel Questionnaire.
(h) Been put on alert for or had active duty military service outside the United States or Canada within the last 2 years? If yes, list countries below and complete Military Questionnaire.
(i) Been convicted, plead guilty, or placed on probation or parole for the commission of any criminal offense in the last 10 years other than a motor vehicle violation, or is the proposed insured currently awaiting trial for such an offense?
(j) Intended for any party other than the owner to obtain any right, title, or interest in any policy issued on the life of the Proposed Insured as a result of this application?
2. Is the Proposed Insured a United States citizen, Canadian citizen, or a lawful permanent resident of the United States (Permanent Residence Card / green card holder)?
3. Please provide details for any "Yes" answers to questions 1a–1j
| Question # | Details |
|---|---|
SECTION IX
Proposed Insured's Tobacco & Nicotine Use
Complete this section if the Proposed Insured is age 18 or over.
1. Have you ever smoked cigarettes (including electronic cigarettes)? If yes, complete 1a and 1b below.
2. Have you ever used smokeless tobacco? If yes, complete 2a and 2b below.
3. Have you ever used tobacco or nicotine dispensing products in any form other than already noted? If yes, complete the table below.
| Type of tobacco / nicotine used | Frequency | Date last used |
|---|---|---|
SECTION X
Medical History
This section must be completed if the Proposed Insured is age 18 or over and is not being medically examined.
1. Does the Proposed Insured have a family history (parents) of heart disease, stroke, or cancer other than basal cell carcinoma? If yes, complete details below.
| Parent | Health condition & date of onset | Current age (if alive) | Age at death (if deceased) | Cause of death (if deceased) |
|---|---|---|---|---|
| Father | ||||
| Mother | ||||
2. In the past 5 years has the Proposed Insured:
(a) Used any controlled substance such as cocaine, heroin, narcotics, amphetamines, barbiturates, sedatives, hallucinogens, or marijuana without a medical prescription?
(b) Been diagnosed with alcoholism or drug dependence by a member of the medical profession, or received treatment, advice, or counseling?
3. Has the Proposed Insured EVER been diagnosed with, treated or tested positive for:
(a) Fainting spells, severe headaches, paralysis, stroke, epilepsy, depression or other mental illness, or any disease or disorder of the brain or nervous system?
(b) Any breathing disorder including asthma, chronic obstructive pulmonary disease (COPD), sleep apnea, or any disease or disorder of the lungs or respiratory system?
(c) Any disease or disorder of the stomach, esophagus, colon, intestines, liver, glands, or digestive system?
(d) High blood pressure, chest pain, heart attack, heart murmur, anemia, or any disease or disorder of the blood, heart, or circulatory system?
(e) Diabetes, kidney disease or disorder, or sugar, albumin, or blood in the urine?
(f) Arthritis, lupus, or any disease or disorder of the back, bones, joints, or muscles?
(g) Cancer, leukemia, tumor, or polyp?
(h) Any sexually transmitted disease (STD)?
(i) Any impairment of hearing or sight, except for the need of corrective lenses?
(j) Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Syndrome (AIDS), or tested positive for anti-bodies to the AIDS virus (except by a home testing kit)?
(k) A weight loss of 15 pounds or more in the past 12 months (except for pregnancy-related weight loss)?
Additional questions
4. Is the Proposed Insured now pregnant? If yes, provide expected due date below.
5. Has the Proposed Insured been prescribed or taken any medication in the last 12 months?
6. In the past 5 years has the Proposed Insured consulted with or been examined or treated by a medical professional for any reason other than an examination required for employment, school, military service, or marriage?
7. In the past 5 years has the Proposed Insured been hospitalized or had an EKG, blood testing (other than HIV or AIDS testing), or other diagnostic testing, or been advised to have a medical test that has not been done?
8. Has the Proposed Insured been advised to have or contemplated having a surgical operation that has not been done?
9. In the past 5 years has the Proposed Insured had any discussions with any doctor, counselor, or medical provider as to any health and/or medical condition not previously revealed in answer to questions 2–8?
10. Please provide details for any "Yes" answers to questions 2–9
| Q # | Impairment / Condition | Dates (from – to) | Complete recovery? | Physician / Hospital — name, address & phone |
|---|---|---|---|---|
11. Personal physician information for the Proposed Insured
| Physician's name | Physician's address | Physician's phone # | Date last seen & reason |
|---|---|---|---|
Sections I, II, III, VIII, IX & X · mylifegameplan.com