Life Insurance

At Associated Insurance Professionals we greatly appreciate your interest in our term life insurance programs and look forward to working with you. Please be aware that this is not an application. This is a request for an application. You are under no obligation by completing this form and no company will receive any of your personal data or information until you receive, review and sign the specific company application you requested. If you have not received a pricing proposal yet, please visit either our "Instant Quote" sections of our website, or call us toll free at (800) 734-6078.

Once you have completed the request form we will transfer your specific detail to the selected company application and return it for your review and signature. Please visit our "Understanding the Application Process" page on this website for more specific details.

Once again, we greatly appreciate your business and look forward to being of further service. When you have completed this form, please click the "Send Information" button appearing at the bottom of this form.

Applicant Information * Full Name
* Last Name
* Date of BirthMM/DD/YYYY
* BirthplaceCity, State and County if applicable
Gender
Marital Status
Social Security NumberEx. 123-45-6789
Driver's License Number123456789
Driver's License State

Residence * Street Address
Street Address Continued
* City
* State
* Zip

Contact * Emailuser@company.com
Group Affiliation
* Home Phoneinclude dashes
Business Phoneinclude dashes
* Best time to reach you

Employer Employer's Name
Address
City
State
Zip

Income Occupation
Annual Earned Income
Is the owner/application someone other than the proposed insured?

Terms of Policy Requested * Company Desired
* Insurance Amount
* Length of TermEx: 20 years
Child Rider
* Number of Units1 unit is $1,000
* Send Notices To
If you selected OTHER above, please specify the name of the person who should receive notices about this policy
* Billing Frequency PreferenceIf you choose the Monthly Option, your monthly premium will be debited automatically from the checking account you specify.

Health Information for Proposed Insured

Please answer the following questions carefully. This information is very important in helping us get your policy issued as soon as possible.

Have the proposed insured ever used any form of tobacco? (This includes cigarettes, chewing tobacco, snuff, etc)
If you answered YES to Question 1 (above), please indicate the quantity and type of tobacco used by the Proposed InsuredEx: # Cigarettes, 20 per day, Yesterday
* Height of Propsed Insured
* Weight
Any abnormal weight loss or gain in the past 12 months?
If you answered YES to Question 5 (above), please indicate the number of lost or gained pounds and the reason

Beneficiary Information

Please enter full name, percentage share, and relationship for proposed unsured for the beneficiaries of this policy.

Primary BeneficiaryExample: Mr. John A. Jones, 50 percent, Father

Contingent BeneficiaryExamples: Mrs. Elizabeth P. Jones, 50 percent, Mother

Total Life Insurance Currently in Force Do you have Life Insurance policies in force?

If yes, please provide the following information about your Life Insurance

Name of Company, Face Amount of Policy, Year of IssueEx: Aetna, $150,000, 1992
Will the policy applied for replace or change any existing life insurance or annuity?

If yes, please provide the following information about the policies/annuities that will be affected.

Name of Company, Face Amount of Policy, Year of IssueEx: Aetna, $150,000, 1992

General Information

Please answer the following questions carefully. This information is very important in helping us get your policy issued as soon as possible.

The following questions apply to the proposed insured. Please give full details to any "YES" questions in the COMMENTS area at the bottom of this section.

In the past five years, have you engaged in flying as a pilot, student pilot, or crew member, or do you intend to become a pilot?

In the past five years, have you engaged in, or contemplated engaging in: ballooning, parachuting, hang gliding, vehicle racing, scuba diving below 60 feet, mountain climbing, or any other similar sport or avocation?

In the past five years, have you had two or more moving violations, been convicted of reckless driving or driving under the influence of alcohol or drugs, or had your driver's license suspended or revoked?

In the next 2 years do you have any plans to travel or reside outside the United States?

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Comments from Above Questions

Health Statement

The following questions apply to the proposed insured. Please give full details in the comments area appearing at the bottom of this section.

a. Have any of your immediate family members (parents, brothers, or sisters) been diagnosed with or died from heart disease, cancer, diabetes, or stroke prior to age 60?

If yes, identify family member, disorder, age at death in comments section.

b. Have you ever had or have you ever been told that you had: high blood pressure, chest pain, stroke, or disease of the heart or blood vessels, cancer or tumor of any kind; epilepsy, mental or nervous disorder; diabetes; lung or respiratory disorder; gastric or intestinal disorder; kidney or urinary tract disorder; disorder of the blood or lympth nodes; or any disease of the reproductive organs?

c. Are you currently taking or have you been advised to take any medication?

Comments from Above QuestionsEx: I am taking ProCardia 200 mg/day. I have diabetes

Senior Care Plus

Senior Care Plus

Life Insurance