Underwriting Submission

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone: *

(###)

###

####

Best time to call: *

A.M.

P.M.

Smoked cigarettes in the past 12 months? *

Yes

No

If "No," used tobacco or nicotine in any other form in the last 12 months?

Yes

No

Used tobacco or nicotine in any form during the past 24 months? *

Yes

No

In the last ten years, received any treatment or advice in relation to alcoholism or the use of alcohol? *

Yes

No

In the last ten years, used barbiturates, narcotics, cocaine, or other controlled substances not prescribed by a physician? *

Yes

No

In the last two years, been treated or attended by a member of the medical profession, or been advised by a member of the medical profession to be admitted to a hospital or other medical facility? *

Yes

No

Ever tested positive for human immunodeficiency virus (HIV) or been treated or diagnosed by a member of the medical profession as having acquired immune deficiency syndrome (AIDS)? *

Yes

No

Been advised of, treated for, or had any known indications of cancer, stroke, heart disorder, respiratory disorder, blood disorder, tumor, kidney disorder, diabetes, high blood pressure, heart or circulatory disorder, or gastrointestinal disorder? *

Yes

No

In the last 5 years been in a motor vehicle accident, been convicted of operating a motor vehicle while under the influence of alcohol or other drugs, been convicted of a moving violation, or received a driver's license restriction or revocation? *

Yes

No

Ever been convicted of a felony? *

Yes

No

Applied for life insurance within the last 10 years and been declined, postponed, rated, or restricted?? *

Yes

No

Currently disabled? *

Yes

No

In the last 3 years been, or now expect to become, a pilot, student pilot, or crew member of any type of aircraft? *

Yes

No

if "yes" what type of license(s) do you have?

Private

Commercial

In the last 3 years taken part in, or now expect to take part in, underwater diving, hang gliding, parasailing, parakiting, parachuting, skydiving, mountain climbing, or organized racing by automobile, motorcycle, motorboat, or snowmobile, or any other form(s) of hazardous activity? *

Yes

No

Contemplate foreign travel? *

Yes

No

Have life insurance coverage (individual or group) in force or an application currently pending? *

Yes

No

Is there a current arrangement or commitment to sell, transfer, assign, or release this policy - or any beneficial interest of this policy or its ownership structer - to a life settlement company, viatical company, bank, investor, or secondary market provider? *

Yes

No