LIFE APPLICATION INTAKE SHEET PROPOSED INSURED INFORMATION Name: (First, Ml. Last) SSN# Maling Address: Yrs. Add: Email Address Home # cP# Birth Date Age’ Birth Place(State/Country) Marital Status Sex Height: Weight: Driver's License: State: Expiration: U.S Ciizen: Y__N_ Status/Type of Visa (GC) Years in US. Employer: Work #: Address: Occupation: #of Years: Annual Income: $ Previous Year: §, Net Worth: § Personal Physician: Phone #: ‘Address: Date Last Visit: Reason: Medications: Do youdrink Alcohol: Y____N___Ifyes, how often & what kind? Do you smoke? Y N if yes, what type & when do u last smoke? Do youexercise?¥___N___ If yes, describe: Do you take any medications? Y__N__(Please write al medications, dosage) Primary Beneficiary: Contingent Beneficiary Name: Relationship: __ Birthday: SSN. Birthday: SSN: CIPOLICY OWNER pratewrtion proceeding) [TADDITONAL INSURED: Name: (First, Ml. Last): SSN# Mailing Adcress: Yrs. Add Email Address: Home #: OP #: Birth Date: Age: Birth Place(State/Country) Marital Status Sex: Height: Weight: Driver's License: State: Expiration U.S Citizen: Y_N_ Status/Type of Visa (GC) Years in US. Employer: Work #: ‘Address: ‘Occupation: # of Years:___ Annual Income: $ Previous Year: § Net Worth: § Visa Expires: Visa Expires: POLICY INFORMATION: IUL:___ TERM: _FA:$ BRS LTC: ___Increasing:___ Level: Annually. Quarterly Monthly: Draft Date: (1# to 27%) Bank: Routing #: Checking # Lab Draw Date: Signature: Signature: Date: Important: For Non-US Citizen: Copy of Visa / Green Card / Working Permit.