IUL Intake Form

Address

Street Address *

City *

State *

Country

Postal code

Phone *

Email *

Date of birth *

Place of Birth *

Is the insured a citizen or permanent resident card holder of the United States? *

Yes

No

SSN/ITIN: *

Drivers license #: *

Primary Medical Provider Information

Primary insured does not have a primary medical provider.

Check here if you do not have a primary medical provider

Primary Medical Provider Name:

Primary Medical Provider Address:

Street Address
Street Address Line 2
City
State
Zip Code

Have you seen a doctor in the last 12 months, reason for visit:

Result of last visit:

Date last seen:

Has the proposed insured ever been diagnosed, received treatment, or been advised to seek treatment by a member of the medical profession regarding:

Any disorder of the heart or blood vessels including but not limited to coronary artery disease, heart attack, heart failure, chest pain, irregular heartbeat, valvular heart disease, congenital heart disease or defect, heart murmur, high blood pressure, or high cholesterol? *

Yes

No

Any disorder of the circulatory system including but not limited to stroke, transient ischemic attack (TIA), aneurysm, carotid artery disease, or peripheral vascular disease? *

Yes

No

Any disorder of the lungs or respiratory system including but not limited to asthma, chronic bronchitis, chronic obstructive pulmonary disease (COPD), emphysema, tuberculosis, or sleep apnea? *

Yes

No

Any disorder of the immune system or endocrine system including but not limited to diabetes, anemia, blood disorder, or thyroid disorder (except those related to the Human Immunodeficiency Virus (AIDS Virus))? *

Yes

No

Cancer, tumors, polyps, or cysts?

Yes

No

Any psychiatric or mental health disorder including but not limited to anxiety, depression, bipolar disorder, schizophrenia, or post-traumatic stress disorder? *

Yes

No

Any neurological or brain disorder including but not limited to epilepsy, seizures, paralysis, multiple sclerosis, Alzheimer's, Parkinson's disease, dementia, or chronic headaches? *

Yes

No

Lupus or other connective tissue disease; any autoimmune disorder? *

Yes

No

Any disease or disorder of the stomach, liver, intestines/colon, or pancreas including but not limited to ulcer, hepatitis, Crohn's disease, or ulcerative colitis? *

Yes

No

Any disease or disorder of the kidneys, bladder or urinary system; prostate, breasts, or reproductive system? *

Yes

No

Any disease or disorder of the muscle, bones, spine, or joints including but not limited to arthritis, fibromyalgia, or chronic pain? *

Yes

No

Any disease or disorder of the skin, eyes, ears, nose or throat? *

Yes

No

Has the proposed Insured ever been diagnosed or treated by a member of the medical profession or tested positive for Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS)? *

Yes

No

Other than previously indicated, in the past 5 years, has the proposed Insured:

Been treated or diagnosed by a member of the medical profession with any mental or physical disorder? *

Yes

No

Had any electrocardiogram (EKG), x-ray, laboratory test, treatment, or procedure? (Excludes tests related to the Human Immunodeficiency Virus (HIV). *

Yes

No

Been hospitalized or had any surgery or procedure? *

Yes

No

Been advised by a member of the medical profession to have any diagnostic test, treatment, surgery or otherprocedure which has not been performed? (Excludes tests related to the Human Immunodeficiency Virus (HIV) *

Yes

No

With or without the recommendation, prescription or knowledge of a medical professional have you undergone any predictive, screening or diagnostic testing including and not limited to genetic or self-administered testing which may lead to a personal health assessment? (Do not answer if you are a resident of DE, NV, or OR. Applicants are not required to answer this question. For MA residents only, failure to answer the question may result in an increased rate or denial of coverage.) *

Yes

No

Has a natural parent or sibling of the proposed Insured died prior to age 60 from coronary artery disease or cancer; or ever been diagnosed or treated by a member of the medical profession for any hereditary disease such as Huntington's disease or polycystic kidney disease? *

Yes

No

Has the proposed Insured ever used tobacco or nicotine substitute in any form including but not limited to cigarettes, cigars, pipes, chewing tobacco, snuff, electronic cigarettes, vaporizer (vape), nicotine gum or patches? If "Yes" answer following question *

Yes

No

Forms used, frequency used, date last used:

Other than previously indicated, specify all medications the proposed Insured is currently taking, or has taken in the past 5 years, including prescription, non-prescription, or herbal remedies.

Primary Insured: Check here if no medications.

Medication name, condition, dosage, frequency, beginning date, primary insured.

If you answered yes to any of the medical questions, please explain details here:

Existing Life Insurance?

Total life insurance on you right now?

Are you planning on cancelling any existing life insurance? *

Yes

No

Do you have group life insurance through work? *

Yes

No

Employer: *

Industry: *

Occupation: *

Years with current employer: *

Months with current employer: *

Earned annual income: *

What is your monthly budget if we started today? *

Primary Beneficiary

How many Primary Beneficiaries do you have? *

Total percentage of All Primary Beneficiaries must total 100% Primary and Contingent Beneficiaries cannot be the same people.

Relationship to insured: The beneficiary is the _______ of the insured. *

Beneficiary %: *

Beneficiary Name: *

Beneficiary Date of birth *

If additional beneficiaries please list here (Name, relationship, %)

Personal History Questions

Has the proposed Insured ever had an insurnace application declined, postponed, or rescinded; ever been offered rated or modified life insurance; ever been refused for renewal or reinstatement? *

Yes

No

Has the proposed Insured traveled or resided outside the U.S. or Canada within the past 2 years or plan to travel outside the U.S. or Canada in the next 2 years? *

Yes

No

Has the proposed Insured ever pleaded guilty or been convicted of a felony, have such charges currently pending, or is the proposed Insured currently on probation or parole? *

Yes

No

Has the proposed Insured used marijuana in any form in the past 5 years? *

Yes

No

Has the proposed Insured ever used heroin, cocaine, narcotics, barbiturates, amphetamines, hallucinogens, or any other controlled substance? *

Yes

No

Has the proposed Insured ever been advised by a member of medical profession to receive treatment for alcohol use or drug dependency on prescribed or non- prescribed drugs? *

Yes

No

Is your father still living? *

Yes

No

Is your mother still living? *

Yes

No

Age of father (Write N/A is not applicable) *

Age of mother (Write N/A is not applicable) *