Option 3 Application – Secured Site for applications

Name *

First

Middle

Last

Address *

Address Line 1

City

State

Zip Code

Have you lived at your current address for less than 6 years?

Email *

Phone *

Birth Date *

Sex *

Male
Female

U.S Citizen *

Martial Status *

Single
Married

Do you currently have life insurance? *

Primary Beneficiary *

Relationship *

Birth Date *

Contingent Beneficiary

Relationship

Birth Date

Paragraph Text

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.

1. Within the last 12 months used, any of the following: walker, wheelchair, electric scooter, supplemental oxygen, or catheter? *

2. Within the past 2 years have you engaged in any motor sports racing; boat racing; parachuting/skydiving; hang gliding; base jumping; rock or mountain climbing; cave diving, underwater photography, canyoning, or Scuba diving over 100 ft.? *

3. In the past 10 years, have you:

a. Used heroin, morphine, other unprescribed narcotics, ecstasy, opium derivatives, marijuana for medical purposes, cocaine, crack, barbiturates, amphetamines, methamphetamines, or hallucinogens or any other illegal, restricted or controlled substances; or been treated or been advised by a licensed member of the medical profession to seek treatment for the intake of any drug? *

b. Used alcohol to a degree that required treatment or was advised to limit or discontinue its use by a licensed member of the medical profession? *

c. Used or been convicted of possession of unlawful drugs or used prescription drugs other than as prescribed by a licensed member of the medical profession in any form? *

d. Been convicted of, pled guilty to, or currently awaiting trial for a felony? *

e. Served or been released from incarceration, probation, parole, or other court-ordered supervision for a misdemeanor or felony conviction? *

4. Are you currently under an order for probation, parole or other court-ordered supervision for a misdemeanor or felony conviction? *

5. Within the past 2 years, have you made any flights as a pilot or student pilot? *

6. Within the next 2 years, do you intend to work, travel, or reside in Saudi Arabia, Iraq, Afghanistan, Syria, Somalia, Sudan, or Yemen for more than 30 days, or reside outside the United States at any location more than 180 days? *

7. Are you a member of the United States Military on active duty? *

8. Do you currently have a valid driver’s license? *

Coverage Amount *

Height *

Weight *

Birth State *

Drivers License Number *

State *

Check to continue with application *

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