Jim's App

LIFE INSURANCE
WEB APPLICATION
"ALWAYS PROTECT THE ONES YOU LOVE"

GENERAL INFO:

* Indicates required field

INSURED'S NAME *

First

Last

Name *

First

Last

DATE OF BIRTH.....01/01/2001 *

Your current age *

What state are you in *

STATE YOU WERE BORN IN *

Address *

Line 1

Line 2

City

State

Zip Code

Country

P.O. BOX if no physical *

SOCIAL SECURITY NUMBER *

GENDER *

DESIRED COVERAGE *

PHONE NUMBER *

Email *

HEIGHT *

WEIGHT *

OWNER INFORMATION:

Is the insured, also the owner? *

No Yes (if yes, skip the owner section)

If the you are the owner/insured leave the next section blank. We already have your information. If someone else, (who is not you) will be the owner, we need his/her information.

OWNER/IF NOT INSURED

POLICY OWNER'S NAME *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

P.O. BOX if no physical *

BIRTH STATE *

DATE OF BIRTH *

SOCIAL SECURITY# *

GENDER *

Phone Number *

Email *

RELATION TO INSURE *

PAYOR INFORMATION:

Is the insured, also the payor? *

No Yes (If yes, skip the payor section)

If the you are the person paying the insurance, leave the next section blank. We already have your information. If someone else, (who is not you) will be making the payments on your behalf, we need his/her information.

PAYOR INFORMATION/
IF NOT INSURED

INSURANCE PAYOR'S NAME *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

P.O. BOX if no physical *

Phone Number *

Email *

RELATION TO INSURE *

WHO'S YOUR BENEFICIARY:

BENEFICIARY:

Name *

First

Last

Phone Number *

RELATION TO INSURE *

Type *

SECONDARY BENEFIARY: (OPTIONAL)

Name *

First

Last

Phone Number *

RELATION TO INSURE *

Type *

TOBACCO QUESTION:

Have you used tobacco and/or nicotine in any form within the past 12 months? *

If yes. please explain *

MEDICAL QUESTION (Section One)

1) Are you now, or within the past 30 days been treated or admitted in a hospital, nursing home, health care facility, long-term care facility, hospice care, or been advised by a licensed member of the medical profession to be confined to a bed ? Have you been medically diagnosed, tested or treated by a licensed member of the medical profession with having a terminal illness resulting in death within the next 12 months? *

If yes. please explain *

2) Within the past 30 days, have you been medically diagnosed, tested or treated in a hospital by a licensed member of the medical profession for a seizure? *

If yes. please explain *

3) Do you need assistance or supervision with dressing, eating, personal hygiene (bathing or toilet), or transferring to or from a bed or chair? *

If yes. please explain *

4) Are you now, or within the past 90 days been diagnosed, tested or treated by a licensed member of the medical profession for any type of tumors or cancers, except basal cell skin cancer? *

If yes. please explain *

5) Have you ever been diagnosed by a licensed member of the medical profession as having Alzheimer’s, dementia, ALS (Lou Gehrig’s disease), sickle cell anemia, hepatitis C, cirrhosis of the liver, cystic fibrosis, brain aneurysm, or organ transplant? *

If yes. please explain *

6) Are you currently receiving dialysis treatment? *

If yes. please explain *

7) Have you ever been diagnosed by a licensed member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or have you tested positive for the Human Immunodeficiency Virus (HIV)? *

If yes. please explain *

MEDICAL QUESTIONS (Section Two)

Do you use any type of insulin medication for any type of diabetes? *

Please Explain *

How many total units per day? *

MEDICAL QUESTIONS(Section Three)

1) Angioplasty, stent implant, bypass surgery, heart valve surgery or pacemaker? *

If yes. please explain *

2) Any type of tumors or cancers, except basal cell skin cancer? *

If yes. please explain *

3) Brain tumor, brain disorders, TIA (mini stroke) or strokes of any kind? *

If yes. please explain *

4) Heart disease of any type, angina, heart attack, enlarged heart, congestive heart failure (CHF), circulatory disorder, or other heart disorders or conditions? *

If yes. please explain *

5) Lung disease, emphysema, or chronic obstructive pulmonary disease (COPD) or any other type of pulmonary or lung disease or condition? *

If yes. please explain *

6) Kidney disease or failure, renal failure or insufficiency, liver disease, hepatitis B, disease of the pancreas or other organ failure or disease? *

If yes. please explain *

7) Diabetes with complications that could include: diabetic coma, insulin shock, eye disease or disorder, neuropathy, amputation, hospitalized for diabetes, take 100 units or more of insulin in a 24-hour period, or insulin use prior to age 40? *

If yes. please explain *

8) Parkinson’s disease, paralysis, multiple sclerosis, lupus, muscular dystrophy, down syndrome, cerebral palsy, epilepsy, seizures or any other neurological disorders? *

If yes. please explain *

9) Paranoia, schizophrenia, major depressive disorder, that includes suicide attempts, hospitalization, or any other mental disorder or disease? *

If yes. please explain *

10) Have you been advised by a licensed member of the medical professional to have tests, surgery, treatment or do you have any medical test results pending or any additional medical evaluations that have not been performed, excluding tests related to the Human Immunodeficiency Virus (AIDS virus)? *

If yes. please explain *

11) Have you received medical treatment, counseling or advised by a licensed member of the medical profession regarding abuse or excessive use of: alcohol, non-prescribed drugs, prescribed drugs, narcotics or any other habit forming substance? *

If yes. please explain *

12) Do you use a medical appliance such as a wheelchair, walker, hospital bed or oxygen? *

If yes. please explain *

CURRENT MEDICATIONS:

Notice our example below, we require:
1. Each prescribed medication
2. The amount of years you've taken it
3. The reason it was originally prescribed
4. The dosage
5. How often you take it daily (or as needed.

Medication name - How many years - reason prescribed - current Dosage - Times daily (or as needed). *

Additional info *

PAYMENT INFORMATION:
(bank draft only)

Bank Name *

Bank Address *

Account Type *

Account Number *

Routing Number *

BILLING INFORMATION:

Does the Proposed Insured receive Social Security, Social Security Disability, SSI, VA Retirement and/or VA Disability? *

Bill Date (1st-28th): *

Submit

YOUR CART

GENERAL INFO:

TOBACCO QUESTION:

MEDICAL QUESTION (Section One)​

MEDICAL QUESTIONS (Section Two)

MEDICAL QUESTIONS(Section Three)

CURRENT MEDICATIONS:

PAYMENT INFORMATION:(bank draft only)

BILLING INFORMATION:​

MEDICAL QUESTION (Section One)

PAYMENT INFORMATION:
(bank draft only)

BILLING INFORMATION: