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ALLCHOICE Agent Information This field is hidden when viewing the form
Select Your Advisor* Jared Bellmund Jack Wingate AJ Brower Heather Bailey Cheyenne Mathews Sara Surigao Michael Reese Ed Johnson Bill Heasley Jeff Hall
LET'S GET STARTED. Check Box To Continue* INSURED INFORMATION Proposed Insured*
First
Last
Maiden (If Applicable)
Date Of Birth
MM slash DD slash YYYY
Gender This field is hidden when viewing the form
Social Security Number
Height
Weight
CONTACT INFORMATION Address
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No. of Years at this address?
Email
Mobile Phone
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Best Time To Call
Birth Country
State of Birth
Marital Status Married Single Divorced Widowed
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Driver's License Number (and State) If Applicable
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Is the Proposed Insured currently employed? Yes No
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Employer Name
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Employer Address
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Occupation
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Duties
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No. of Years at Employer
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Employer Phone
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BENEFICIARIES This field is hidden when viewing the form
Primary Beneficiary
First
Last
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Beneficiary Address
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Relation To Insured
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Beneficiary Date Of Birth
MM slash DD slash YYYY
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Beneficiary Social (if you have it)
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Beneficiary Notes
State if more than 1 Beneficiary or if you want to include Contingent Beneficiary (complete the form then discuss with your agent)
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OTHER COVERAGE INFORMATION This field is hidden when viewing the form
Is the policy applied for intended to replace any existing life insurance or annuity policies with this or any other company? No Yes
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Explanation
Explain why you are replacing the current contract
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Do you have any other life insurance or annuities in force, or are you currently applying for any other life insurance beside the insurance being applied for in this application? No Yes
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Current Life Insurance Carrier
If more than 1 - please list all separated by a comma
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Current Life Insurance Coverage Amount
If more than 1 - please list all separated by a comma
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Current Life Insurance Policy Number(s)
If more than 1 - please list all separated by a comma
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Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract? Yes No
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Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract? Yes No
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Would you like the State Replacement Notice read aloud? No Yes
PLAN INFORMATION Proposed Insured Face Amount (Death Benefit)
Purpose Of Insurance Business Personal Both
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Optional Benefit Riders (check to include) This field is hidden when viewing the form
Premium Mode Monthly EFT Quarterly Annual
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Send Premium Notices to: Insured's Address Other Address
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Other Address
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BANK INFORMATION **Please Note - If You Select Monthly EFT we MUST have your routing and account number. If you do not enter that information, we will change the pay mode to Quarterly and we will have to amend the policy at the time of issue
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Name on Account
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Name of Bank
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Type Of Account Checking Savings
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Account Number
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Routing Number
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I authorize the Life Insurance Carrier to debit all initial premium required to place this policy active. I understand that the debit for the initial premium will occur upon policy issue and receipt of all applicable delivery requirements. Yes No
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NON-MEDICAL UNDERWRITING This field is hidden when viewing the form
Has the proposed insured applied for or received disability benefits in the last 5 years? This field is hidden when viewing the form
If Yes, explain
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Has the proposed insured applied for life or health insurance that was declined, postponed, or modified, or had reinstatement of an insurance policy denied? This field is hidden when viewing the form
If Yes, explain
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Has the proposed insured flown as a pilot or crew member within the last 2 years, or does the Proposed Insured intend to do so in the next 2 years? This field is hidden when viewing the form
If Yes, Explain
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Has the proposed insured had more than 2 moving motor vehicle violations in the last 3 years? This field is hidden when viewing the form
If yes, Explain
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Has the proposed insured had his/her driver's license in a state of revocation, restriction, or suspension, or had a driving while intoxicated or driving under the influence of alcohol or drugs in the last 5 years? This field is hidden when viewing the form
If yes, Explain
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Has the proposed insured engaged in scuba diving, auto or motorcycle racing, rock or mountain climbing, ultra light flying, hand gliding, or sky diving in the last 2 years, or does the proposed insured intend to do so in the next 2 years? This field is hidden when viewing the form
If yes, Explain
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Has the proposed insured traveled outside the United States or Canada in the last 2 years, or does the proposed insured intend to do so in the next 2 years? This field is hidden when viewing the form
If yes, Explain
Include the following:
1. Destination
2. Date (Start & End)
3. Purpose (Example - Vacation / Business / Etc)
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Has the proposed insured been put on alert for, or had active duty military service outside the United States of Canada within the last 2 years? This field is hidden when viewing the form
If yes, Explain
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Has the proposed insured been convicted, plead guilty or placed on probation or parole for the commission of any criminal offense in the last 10 years other than a motor vehicle violation or is the proposed insured currently awaiting trial for such an offense? This field is hidden when viewing the form
If yes, Explain
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Has the proposed insured intended for any party other than the owner to obtain any right, title, or interest in any policy issued on the life of the proposed insured as a result of this application? This field is hidden when viewing the form
If yes, Explain
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Is the proposed insured a US or Canadian citizen or permanent US Resident This field is hidden when viewing the form
Please provide country or citizenship and type of visa (if applicable, provide green card #)
TOBACCO AND NICOTINE USE Have you ever smoked cigarettes (including Electronic Cigarettes)? Details (Current Smoker? Past Smoker? if past - include date quit)
Have you ever used smokeless tobacco? Details (Current User? Past User? if past - include date quit)
Have you ever used tobacco or nicotine dispensing products in any form other than already noted including but not limited to pipe, cigar, hookah smoking, or nicotine gum/patches? Details (include "what", if current...if past include date of last use)
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PRIMARY PHYSICIAN This field is hidden when viewing the form
Do You Have A Primary Physician? This field is hidden when viewing the form
Physician Name, or Practice Name, or None
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Physican | Practice Address
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Physician | Practice Phone
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Date Last Seen (approx if you don't know)
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Reason for visit, findings, treatment (if any)
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MEDICAL & SUPPLEMENTAL QUESTIONS This field is hidden when viewing the form
Do You Want To Answer Medical Questions NOW?* No Yes
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Are You Applying For The Supplemental Long Term Care Rider?* No Yes
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MEDICAL HISTORY This field is hidden when viewing the form
Does the Proposed Insured have a family history (parents) of heart disease, stroke or cancer other than basal cell carcinoma? This field is hidden when viewing the form
Father Yes No
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Is Your Father Still Alive Yes No
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Please list health condition and date of onset - Father
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Mother Yes No
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Is Your Mother Still Alive Yes No
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Please list health condition and date of onset - Mother
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In Past 5 Years Has The Insured: This field is hidden when viewing the form
Used any controlled substance, such as cocaine, heroin, narcotics, amphetamines, barbiturates, sedatives, hallucinogens, or marijuana without a medical prescription? This field is hidden when viewing the form
Details Of Impairment/Condition
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Dates (From - To)
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Complete Recovery This field is hidden when viewing the form
Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
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Been diagnosed with alcoholism or drug dependence by a member of the medical profession or received treatment, advice, or counseling from any physician, counselor, or other medical provider? This field is hidden when viewing the form
Details Of Impairment/Condition
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Dates (From - To)
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Complete Recovery This field is hidden when viewing the form
Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
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Has the Proposed Insured EVER been diagnosed with, treated or tested positive for, or been given medical advice by a member of the medical profession for: This field is hidden when viewing the form
Fainting spells, severe headaches, paralysis, stroke, epilepsy, depression or other mental illness or any disease or disorder of the brain or nervous system? This field is hidden when viewing the form
Details Of Impairment/Condition
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Dates (From - To)
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Complete Recovery This field is hidden when viewing the form
Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
Any breathing disorder including asthma, chronic obstructive pulmonary disease (COPD), sleep apnea, or any disease or disorder of the lungs or respiratory system? This field is hidden when viewing the form
Details Of Impairment/Condition
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Dates (From - To)
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Complete Recovery This field is hidden when viewing the form
Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
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Any disease or disorder of the stomach, esophagus, colon, intestines, liver, glands or digestive system? This field is hidden when viewing the form
Details Of Impairment/Condition
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Dates (From - To)
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Complete Recovery This field is hidden when viewing the form
Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
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High blood pressure, chest pain, heart attack, heart murmur, anemia, or any disease or disorder of the blood, heart or circulatory system? This field is hidden when viewing the form
Details Of Impairment/Condition
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Dates (From - To)
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Complete Recovery This field is hidden when viewing the form
Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
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Diabetes, kidney disease or disorder, or sugar, albumin, or blood in the urine? This field is hidden when viewing the form
Details Of Impairment/Condition
Dates (From - To)
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Complete Recovery This field is hidden when viewing the form
Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
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Arthritis, lupus, or any disease or disorder of the back, bones, joints or muscles? This field is hidden when viewing the form
Details Of Impairment/Condition
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Dates (From - To)
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Complete Recovery This field is hidden when viewing the form
Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
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Cancer, leukemia, tumor, or polyp? This field is hidden when viewing the form
Details Of Impairment/Condition
Dates (From - To)
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Complete Recovery This field is hidden when viewing the form
Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
Physician / Facility Address
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Physician / Facility Phone
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Any sexually transmitted disease (STD)? This field is hidden when viewing the form
Details Of Impairment/Condition
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Dates (From - To)
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Complete Recovery This field is hidden when viewing the form
Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
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Any impairment of hearing or sight, except for the need of corrective lenses? This field is hidden when viewing the form
Details Of Impairment/Condition
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Dates (From - To)
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Complete Recovery This field is hidden when viewing the form
Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
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Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Syndrome (AIDS) or tested positive for anti-bodies to the AIDS virus (except by a home testing kit)? This field is hidden when viewing the form
Details Of Impairment/Condition
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Dates (From - To)
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Complete Recovery This field is hidden when viewing the form
Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
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A weight loss of 15 pounds or more in the past 12 months (except for pregnancy-related weight loss)? This field is hidden when viewing the form
Details Of Impairment/Condition
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Dates (From - To)
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Complete Recovery This field is hidden when viewing the form
Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
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Is the Proposed Insured now pregnant? This field is hidden when viewing the form
Expected Due Date
MM slash DD slash YYYY
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Has the Proposed Insured been prescribed or taken any medication in the last 12 months? This field is hidden when viewing the form
Details Of Impairment/Condition
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Dates (From - To)
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Complete Recovery This field is hidden when viewing the form
Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
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In the past 5 years has the Proposed Insured consulted with or been examined or treated by a medical professional for any reason other than an examination required for employment, school, military service, or marriage? This field is hidden when viewing the form
Details Of Impairment/Condition
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Dates (From - To)
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Complete Recovery This field is hidden when viewing the form
Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
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In the past 5 years has the Proposed Insured been hospitalized or had an EKG, blood testing (other than HIV or AIDS testing) or other diagnostic testing or been advised to have a medical test that has not been done? This field is hidden when viewing the form
Details Of Impairment/Condition
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Dates (From - To)
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Complete Recovery This field is hidden when viewing the form
Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
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Has the Proposed Insured been advised to have or contemplated having a surgical operation that has not been done? This field is hidden when viewing the form
Details Of Impairment/Condition
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Dates (From - To)
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Complete Recovery This field is hidden when viewing the form
Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
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In the past 5 years has the Proposed Insured had any discussions with any doctor, counselor, or medical provider as to any health and/or medical condition, disorder or diagnosis not previously revealed in answer to previous questions? This field is hidden when viewing the form
Details Of Impairment/Condition
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Dates (From - To)
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Complete Recovery This field is hidden when viewing the form
Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
SUPPLEMENTAL MEDICAL HISTORY (FOR LTC RIDER) This field is hidden when viewing the form
Are You Covered By Medicaid? (Note This Does NOT Mean Medicare) This field is hidden when viewing the form
In the last 2 years, have you been declined, refused, rated or turned down for long-term care insurance, chronic illness rider or a long-term care insurance rider? This field is hidden when viewing the form
Reason And Company
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Are you currently confined to a nursing facility, receiving home health care, using adult day care services, residing in an assisted living facility, receiving hospice care or in the last 12 months have you used or been advised by a member of the medical profession to use any such confinement or care? This field is hidden when viewing the form
Details
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Do you require assistance or supervision in performing any of the following activities: eating, dressing, bathing, toileting, bowel or bladder control, transferring from bed to chair, mobility or taking medications? Details
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Do you use or have you been advised by a member of the medical profession to use a walker, multi prong cane, wheelchair, crutches, motorized scooter, hospital bed, stair lift, oxygen (excluding CPAP), dialysis machine or any other assistance device? Details
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In the last 2 years, have you had multiple falls or any fall that resulted in a fracture that has been treated, examined or advised by a member of the medical profession? This field is hidden when viewing the form
Details & Diagnosis
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Date Of Onset
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Treatments And/Or Medications Prescribed
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Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
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Have you been diagnosed or treated by a member of the medical profession, been prescribed or taken medication for: This field is hidden when viewing the form
Alzheimer’s disease, dementia, recurrent or chronic memory loss, mild cognitive impairment (MCI) or organic brain syndrome? This field is hidden when viewing the form
Details & Diagnosis
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Date Of Onset
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Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
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Multiple sclerosis, Parkinson’s disease, stroke or Transient Ischemic Attack (TIA), muscular dystrophy or ALS (Lou Gehrig’s disease)? This field is hidden when viewing the form
Details & Diagnosis
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Date Of Onset
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Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
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Any disorder or disease requiring the use of narcotic or opioid pain medications? This field is hidden when viewing the form
Details & Diagnosis
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Date Of Onset
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Attending Physician / Facility - Same As Regular Physician / Facility? This field is hidden when viewing the form
Physician Name Or Medical Facility
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Physician / Facility Address
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Physician / Facility Phone
PURPOSE OF INSURANCE Check All That Apply This field is hidden when viewing the form
Approximate Annual Income (Business or Personal)
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Estimated Net Worth (P) or Business Value (B)
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In the past 5 years has the proposed insured filed for bankruptcy or had any liens/judgements filed against him/her? This field is hidden when viewing the form
Has the bankruptcy been discharged or lien/judgement satisfied? This field is hidden when viewing the form
Provide date of discharge
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Details
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PAPERLESS DELIVERY This field is hidden when viewing the form
Does the insured elect to receive all applicable policy pages, billing notices, privacy notices, disclosures, authorizations, acknowledgements, tax forms and other documents relating to their policy in electronic form to the e-mail address provided? 
