Kid’s Whole Life Application – Secured Site for applications

Primary Beneficiary *

Relationship *

Birth Date *

Do you have a Contingent Beneficiary? *

Yes
No

Contingent Beneficiary *

Relationship *

Birth Date *

Child 1 Name *

First

Last

Birth Date *

Sex *

Male
Female

Plan Type: *

10 Pay
Pay to 100

Coverage Amount *

Relationship to child *

Another Child? *

Yes
No

Child 2 Name *

First

Last

Birth Date *

Sex *

Male
Female

Plan Type: *

10 Pay
Pay to 100

Coverage Amount *

Relationship to child *

Another Child? *

Yes
No

Child 3 Name *

First

Last

Birth Date *

Sex *

Male
Female

Plan Type: *

10 Pay
Pay to 100

Coverage Amount *

Relationship to child *

Another Child? *

Yes
No

Child 4 Name *

First

Last

Birth Date *

Sex *

Male
Female

Plan Type: *

10 Pay
Pay to 100

Coverage Amount *

Relationship to child *

Another Child? *

Yes
No

Child 5 Name *

First

Last

Birth Date *

Sex *

Male
Female

Plan Type: *

10 Pay
Pay to 100

Coverage Amount *

Relationship to child *

Another Child? *

Yes
No

Child 6 Name *

First

Last

Birth Date *

Sex *

Male
Female

Plan Type: *

10 Pay
Pay to 100

Coverage Amount *

Relationship to child *

Another Child? *

Yes
No

Child 7 Name *

First

Last

Birth Date *

Sex *

Male
Female

Plan Type: *

10 Pay
Pay to 100

Coverage Amount *

Relationship to child *

Another Child? *

Yes
No

Child 8 Name *

First

Last

Birth Date *

Sex *

Male
Female

Plan Type: *

10 Pay
Pay to 100

Coverage Amount *

Relationship to child *

1. Have any of the Children ever been diagnosed with, received or been advised to receive treatment, medical care, or surgical care, or been prescribed medication, or investigated for:

a) A type of heart disease, birth defect, Down’s Syndrome, autism, a mental disorder or developmental problems? *

Yes
No

Which Child and what was the diagnoses? *

b) A form of cancer, leukemia, Cystic Fibrosis, chronic lung disease (excluding asthma), spinal atrophy, muscular dystrophy or diabetes? *

Yes
No

Which Child and what was the diagnoses? *

c) A terminal illness or end-stage disease? *

Yes
No

Which Child and what was the diagnoses? *

2. Within the past 5 years (60 months), has any of the children had a diagnostic test, been advised to get surgery, a medical procedure or a lab test (excluding tests related to Human Immunodeficiency Virus (HIV)), or been referred to a doctor or medical specialist, any of which has not yet been started or completed or for which the results are not yet known? *

Yes
No

Which Child and what was the diagnoses? *

Check box here in order to proceed with application. *

Check box here

Owner and Payer's Social Security Number *

Name of Financial Institution *

Bank Routing Number *

Bank Account Number *

Payment date *