Insurance Company

Life Home Office: 3120 139th Ave SE Suite 300, Bellevue, WA 98005 / 1-800-238-9671
Mailing address: PO Box 248831, Oklahoma City, OK 73124-8831

Application Application ID/Policy Number:

For Individual Life Insurance

A Personal Information

Proposed Insured{/Policy Owner}:

Full Legal Name (First, Middle, Last, Suffix):
Residence Address (Street, House/Apt. Number):
City: State: Zip Code:
Mailing Address (If applicable):
City: State: Zip Code:
Phone Number: Email Address:
Sex at Birth:  Male  Female Date of Birth (MM/DD/YYYY):
Place of Birth:

Are you a United States Citizen or Permanent Resident (Green Card)?  Yes  No

US Tax Identification Number (ITIN/SSN/None):

Do you have a US Driver’s License?  Yes  No If “Yes,” License Number:

License State of Issue: License Expiration Date:

When was the last time you used Tobacco or Nicotine products in any form (e.g. cigarettes, pipes, cigars, snuff,
chewing tobacco or nicotine delivery device such as gum or patch, etc.)?
 Never  In the past 12 months  More than 12 months

Occupation: Earned Annual Income:

Face Amount Requested: Product:

Rider(s):  Waiver of Premium
 Accelerated Benefit Rider – Terminal Illness*
 Chronic Illness Accelerated Benefit Rider*
*Automatically included at no additional premium. Policy Owner may request removal of the rider at any time.

Primary Purpose of Insurance:

Proposed Policy Owner (First, MI, Last, Suffix):

Residence Address (Street, House/Apt. Number):
City: State: Zip Code:

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Primary Beneficiary (First, MI, Last, Suffix):
Relationship to Insured: % of Share:
Primary Beneficiary (First, MI, Last, Suffix):
Relationship to Insured: % of Share:

Contingent Beneficiary (First, MI, Last, Suffix):

Relationship to Insured: % of Share:
Contingent Beneficiary (First, MI, Last, Suffix):
Relationship to Insured: % of Share:

Secondary Addressee Name (First, MI, Last, Suffix):

Address (Street, House/Apt. Number):
City: State: Zip Code:

B Medical Information
1. Provide the following:
Your Height & Weight Today:
Name & Address of Primary Care Physician/Health Care Provider:

Date & Reason for Last Visit:

2. On average do you consume two or more alcoholic beverages every day?  Yes  No
3. How often do you use marijuana or products containing CBD/THC?
 None  Four times or less per week  Five times or more per week
4. Have you, in the past five years, been treated for, been hospitalized for, or diagnosed by a member
of the medical profession as having Human Immunodeficiency Virus (HIV) antibodies or antigens or
Acquired Immune Deficiency Syndrome (AIDS) or AIDS related Complex (ARC) or any other immune
deficiency disorder; or have you tested positive for HIV antibodies or antigens?  Yes  No
5. Have you, in the past five years, consulted with, been diagnosed or treated by a member of the
medical profession or hospitalized, or taken medication for the following conditions?
Please mark all that apply:
a. Mental Health Impairments  Yes  No
b. Neurological Impairments  Yes  No
c. Musculoskeletal Impairments  Yes  No
d. Cancer/Tumor/Mass/Skin Disorders  Yes  No
e. Cardiovascular Impairments  Yes  No
f. Endocrine Impairments/Blood Disorders  Yes  No
g. Gastrointestinal Impairments  Yes  No
h. Urinary/Genital Impairments  Yes  No
i. Respiratory Impairments  Yes  No
6. In the past five years, have you been disabled, or unable to work due to any medical condition other
than resulting in maternity, routine surgeries/procedures, or been advised to have any procedure
that has not been completed against physician advice?  Yes  No
7. Have you ever used, or been treated for the use of amphetamines, barbiturates, cocaine, opiates,
hallucinogens or any other illegal drugs or have you been treated by or consulted a member
of the medical profession for the abuse of prescription drugs or received treatment
for alcohol dependency?  Yes  No

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 C Non-Medical Information
1. Have you, in the past two years, flown as a student pilot, pilot or crewmember?  Yes  No

2. Have you, in the past two years, taken part in hang-gliding, parasailing, parachuting, skydiving,
ultralight, soaring, ballooning, bungee jumping, rock or mountain climbing, organized racing by
automobile, motorcycle, powerboat or snowmobile, or underwater diving?  Yes  No

3. Have you, in the past ten years, pled guilty to or been convicted of a felony or misdemeanor, or are
such charges pending against you, or are you currently on parole or probation?  Yes  No

4. Do you have any plans to travel, work or reside outside the US in the next two years?  Yes  No

5. Have you had an application for life, accident, or health insurance, or reinstatement of a policy,
declined, postponed, cancelled or issued other than as applied for?  Yes  No

D Other Insurance/Replacement
1. Is there any life insurance policy or annuity contract inforce or application pending on the life of the
proposed insured, including policies sold or assigned to a trust or viatical/life settlement company?  Yes  No

2. Will any life insurance policy or annuity contract on the proposed insured be reduced, replaced,
discontinued or payment of premium stopped, if the insurance applied for is issued?  Yes  No

E Billing Method & Initial Payment

Billing Method:

 Electronic Funds Transfer (EFT) – Monthly Deduction

 Bill from same account as Policy Number(s):

Account Holder’s Name:

 Checking Account  Savings Account
Only enter United States Checking or Savings account information below:
Bank Routing Number:
Bank Account Number:
Draft Day:
I request and authorize Insurance Company to make monthly withdrawals against my US Checking/Savings
account which I will provide upon approval of my life insurance policy. This authority is to remain in effect until
Incurance Co has received appropriate notice of its termination in such time and manner as to afford Incurance
Co reasonable opportunity to act upon it. I understand and agree that if such withdrawal is returned by my
financial institution, Incurance Co shall be under no liability for the returned check and that the returned check
may result in a lapse of coverage.

 Direct Bill:
 Annual  Semi-Annual  Quarterly  Monthly

Initial Payment:
How would you like to pay your first premium payment?
 Pay with the bank account provided
 Pay with Credit/Debit Card
Total payment collected with application: $

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