Life Insurance Application | Resources

About You

Full Name *

Date of Birth *

Biological Sex *

Height

Weight

Phone Number *

Email *

Address

City

State

Zip Code

Citizenship & Travel

Are you a U.S. citizen? *

Yes No

If no: What is your country of citizenship?

Do you have a Green Card?

Yes No

What type of visa do you have (if any)?

Are you planning to travel internationally in the next 12 months?

Yes No

If yes: Where and when?

Financial Information

This information helps underwriters provide appropriate coverage options

What is your monthly income?

What is your estimated net worth?

What is your job title or industry?

Coverage Preferences

What kind of life insurance are you interested in? (Check all that apply)

How much coverage do you think you need?

Will you be financing premiums?

Are you replacing an existing policy?

Yes No

Replacement Policy Disclosure

Important Notice: You have indicated that you are replacing an existing insurance policy. Before proceeding, please carefully consider the following important information.

Potential Consequences of Replacement:

Surrender Charges: Your existing policy may have surrender charges or fees that will apply if you cancel or replace it. These charges can significantly reduce the cash value you receive.
New Contestability Period: A new policy will have a new contestability period, typically two years, during which the insurance company may contest claims based on material misrepresentations.
New Suicide Clause: A new policy will have a new suicide clause, typically two years, during which death by suicide may not be covered.
Higher Premiums: You may face higher premiums due to your current age and health status, which may have changed since you purchased your original policy.
Loss of Benefits: Your existing policy may have benefits, riders, or features that may not be available or may be more expensive in a new policy.
Underwriting Requirements: You will need to undergo new underwriting, and there is no guarantee that you will be approved for the same or better coverage.

1035 Exchange: If you are transferring funds from an existing policy through a 1035 exchange, the exchange may provide tax benefits. However, you should consult with a tax advisor to understand the full implications of a 1035 exchange in your specific situation.

Recommendation: Before replacing your existing policy, we strongly recommend that you:

Review your existing policy carefully with your current insurance advisor
Compare the features, benefits, and costs of both policies
Consider all fees, charges, and potential tax implications
Consult with a tax advisor or financial planner if appropriate

Your Rights: You have the right to cancel this application at any time before the new policy is issued. You also have the right to receive a copy of the replacement comparison statement that compares your existing policy with the proposed new policy.

I acknowledge that I have read and understand this Replacement Policy Disclosure. I understand the potential consequences of replacing my existing insurance policy, and I am proceeding with this replacement of my own free will. *

Notice: This disclosure is provided to help you make an informed decision about replacing your existing insurance policy. Please take the time to carefully review and understand all information provided before proceeding.

If yes: Will any 1035 exchange money be transferred?

Yes No

Notice of Privacy Practices - Health Information Protection

Important: The information you provide in the health-related sections of this application is considered Protected Health Information (PHI) under the Health Insurance Portability and Accountability Act (HIPAA).

How We Use Your Health Information: We use your health information to evaluate your insurance application, determine eligibility for coverage, and process underwriting. We may share this information with:

Insurance companies and their representatives for underwriting purposes
Medical information bureaus and other authorized third parties
Our affiliates and service providers who assist in processing your application

Your Rights: You have the right to:

Request access to your health information
Request amendments to your health information
Request restrictions on how we use or share your information
Request confidential communications
File a complaint if you believe your privacy rights have been violated

Our Responsibilities: We are required by law to maintain the privacy and security of your protected health information. We will notify you promptly if a breach occurs that may have compromised the privacy or security of your information.

For more detailed information about our privacy practices, please review our complete HIPAA Privacy Notice.

I acknowledge that I have read and understand this Notice of Privacy Practices. I understand how my health information will be used and disclosed, and I acknowledge my rights as described above. *

Privacy Officer Contact: If you have questions about our privacy practices or wish to file a complaint, please contact our Privacy Officer at [email protected] or by mail at the address provided in our full privacy notice.

Health Information

Who is your primary doctor (name + location)?

When was your last visit and why?

Are you getting ongoing treatment for any conditions?

Yes No

If yes: Please share details.

Any specialists or hospital visits in the past 5 years?

Prescriptions

Do you take any prescription medications?

Yes No

If yes: What are they for and who prescribed them?

Family History

Lifestyle & Habits

Risk Activities

Optional, but helpful for accurate underwriting

Do you fly planes, scuba dive, rock climb, race cars, or do other high-risk hobbies?

Major Conditions

Check if any apply

Health Portals & Digital Access

Are you able to log in to a patient portal (like MyChart) to access your medical records?

Additional Health Information

Optional, but may help with your application

Do you:

Exercise regularly? (Type + Frequency)

Get annual physicals or wellness tests?

Yes No

Have a recent EKG, colonoscopy, or mammogram?

Yes No

Consent & Communication

By submitting this form, you agree to be contacted via phone, email, or text by Daniel Speiss or authorized representatives for insurance-related purposes. Your information will only be used to evaluate your insurance needs and will not be sold or misused.

Consent & Authorization

Digital Signature *

Please type your full name to authorize us to begin reviewing your application. This is a HIPAA-compliant step required to work with insurance carriers.

I acknowledge and agree to the Terms of Use and Privacy Policy .

Life Insurance Application – Individual

Licensed Insurance Services

About You

Citizenship & Travel

Financial Information

Coverage Preferences

Replacement Policy Disclosure

Notice of Privacy Practices - Health Information Protection

Health Information

Prescriptions

Family History

Lifestyle & Habits

Risk Activities

Major Conditions

Health Portals & Digital Access

Additional Health Information

Consent & Communication

Consent & Authorization

Producer Compensation Disclosure

Application Submitted Successfully!

Submission Error