Option 2 Application – Secured Site for applications

Name *

First

Middle

Last

Address *

Address Line 1

City

State

Zip Code

Email *

Phone *

Birth Date *

Sex *

Male
Female

U.S Citizen *

Primary Beneficiary *

Relationship *

Birth Date *

Do you have another Primary Beneficiary? *

Do you a Contingent Beneficiary (if the primary isn't alive anymore)? *

Do you currently have life insurance? *

1. Have you been medically treated or diagnosed by a medical professional as having Acquired Immune Deficiency Syndrome (AIDS), AIDS related complex (ARC), or any immune deficiency related disorder or tested positive for the Human Immunodeficiency Virus (HIV)? *

2. Within the past 12 months, have you:

a. made any flights as a pilot, student pilot or crew member of any aircraft? *

b. participated in motorized racing, hang gliding, rock or mountain climbing, rodeo events, sky diving, or skin or scuba diving? *

c. had any diagnostic testing (excluding AIDS/HIV tests), surgery or hospitalization recommended by a medical professional which has not been completed or for which the results have not been received? *

3. Within the past 2 years, have you been treated, diagnosed, or prescribed medication by a medical professional for:

a. chronic bronchitis, emphysema, chronic obstructive pulmonary disease (COPD), seizures, blood clot, aneurysm, stroke, TIA, heart attack, congestive heart failure (CHF)? *

b. internal cancer, melanoma, Hodgkin’s disease, lymphoma, leukemia, or multiple myeloma? *

c. mental retardation, autism, bi-polar, schizophrenia, Alzheimer’s, dementia, memory loss, or a suicide attempt? *

d. liver or kidney failure, renal insufficiency (including dialysis), Hepatitis C, chronic hepatitis, cirrhosis, had an amputation caused by disease or had been advised to have an organ transplant? *

4. Within the past 3 years, have you:

a. used narcotics, barbiturates, amphetamines, hallucinogens, heroin, cocaine, cannabis, marijuana or other habit forming drugs, except as prescribed by a physician; or received medical treatment or counseling for, or been advised by a physician to discontinue, the use of alcohol or prescribed or non-prescribed drug? *

b. plead guilty to or have been convicted of a felony or misdemeanor (including DUI or DWI) or do you have such a charge currently pending against you or have you had a driver’s license suspended or revoked or is currently suspended or revoked? *

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Please provide any information for any questions that were answered yes. If you want any more Primary or Contingent Beneficiaries, please add here with name, relationship and percentage. If there are riders you want or have questions, please enter here as well.

Coverage Amount *

Height *

Weight *

Birth State *

Drivers License Numbers *

State *

Check box here in order to proceed with application. *

Check box here