Insured's Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Insured's Sex *

M

F

Date of Birth *

MM

DD

YYYY

Tabacco User: *

Yes

No

Use to be

Date Last Used: *

MM

DD

YYYY

Type of Use: *

Cigarette

Cigar

Chew/Snuff

Patch

Gum

Electric Cigarette

Other

N/A

Type of Policy Requested: *

Term

Permanent

Survivorship

Unsure

Face Amount *

$250,000

$500,000

$1,000,000+

$3,000,000+

Unsure

In the last 5 years have you engaged in any of the following activities: private pilot, scuba/skin diving, organized motor vehicle racing (i.e. snowmobile or motorboat), skydiving, hang gliding, mountain climbing, or rodeo? *

If "yes", describe in space below.

Yes

No

In the last 5 years have you traveled outside the U.S. or Canada? Any future plans to travel abroad? *

If "yes", describe in space below.

Yes

No

In the last 5 years have you been in an auto accident, convicted of a driving while intoxicated, or have more than two moving violations? *

If "yes", describe in space below.

Yes

No

In the last 5 years have you been on parole or probation or convicted of a felony or misdemeanor? *

If "yes", describe in space below.

Yes

No

In the last 5 years you regularly used, or are you currently using marijuana or any other controlled substance? *

If "yes", select type below.

Yes

No