Erie Insurance Express Life Insurance Application Questions Learn More About: Life Insurance ALLCHOICE Agent InformationSelect Your Advisor*Heather BaileyAJ BrowerCheyenne MathewsMichael ReeseEd JohnsonBill HeasleyJeff HallJared BellmundJack WingateINSURED INFORMATIONProposed Insured* First Last Maiden (If Applicable) Date Of Birth MM slash DD slash YYYY Gender Female Male Social Security Number Height Weight CONTACT INFORMATIONAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code No. of Years at this address? Email Mobile PhoneBest Time To Call Birth Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country State of Birth AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Marital StatusMarriedSingleDivorcedWidowedDo you authorize the release of the health related information to your Erie Family Life Agent? Yes No Driver's License Number (and State) If Applicable Is the Proposed Insured currently employed?YesNoEmployer Name Employer Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Occupation DutiesNo. of Years at Employer Employer PhoneBENEFICIARIESPrimary Beneficiary First Last Beneficiary Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Relation To Insured Beneficiary Date Of Birth MM slash DD slash YYYY Beneficiary Social (if you have it) Beneficiary NotesState if more than 1 Beneficiary or if you want to include Contingent Beneficiary (complete the form then discuss with your agent)PLAN INFORMATIONProposed Insured Face Amount (Death Benefit)Maximum Amount Of Coverage is $500,000 Premium Mode*SELECT PAY PLANMonthly EFTAnnual EFTAnnual - BillSend Premium Notices to:Insured's AddressOther AddressOther Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 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 issueName on Account Name of Bank Type Of AccountCheckingSavingsAccount Number Routing Number 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.YesNoEXPRESS UNDERWRITING QUESTIONSTobacco Usage* Never Used Past User - Quit Over 24 Months Ago Current User (or quit within last 24 months) Are you a member or have you entered into a written agreement to become a member of the United States Armed Forces?* No Yes In the past 10 years, have you used any controlled substance (other than marijuana) such as cocaine, heroin, opioids, narcotics, barbiturates, amphetamines, sedatives or hallucinogens without a medical prescription?* No Yes Have you ever been convicted of or pled guilty or no contest to any felony or are you currently under indictment, awaiting trial or sentencing, or on probation or parole?* No Yes In the past 5 years, have you ever had or been advised by a member of the medical profession to have a kidney, liver, heart or other internal organ transplant?* No Yes Have you ever been diagnosed with, treated, tested positive for, or been given medical advice by a member of the medical profession for:***CHECK ALL THAT APPLY** NONE OF THESE APPLY Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS)? Any disease or disorder of the heart including, but not limited to: coronary artery disease, heart attack, coronary artery bypass, angioplasty or stents, heart valve disorder or surgery? Any disease or disorder of the brain or nervous system including, but not limited to: multiple sclerosis, Parkinson's disease, stroke or transient ischemic attack (TIA), aneurysm, muscular dystrophy, ALS (Lou Gehrig's disease), or paralysis? Any cancer (other than non-melanoma skin cancer) including, but not limited to: malignant tumors, lymphoma, Hodgkin's disease, leukemia, or melanoma? Diabetes, kidney disease or disorder, hepatitis B or C, fibrosis or cirrhosis of the liver? Any disease requiring the use of oxygen including, but not limited to: emphysema or chronic obstructive pulmonary disease (COPD)? Bi-polar disorder, schizophrenia, psychosis, suicide attempt or post-traumatic stress disorder (PTSD)? In the past 2 years, have you been hospitalized for any reason (other than pregnancy and normal delivery)? PRIMARY PHYSICIANDo You Have A Primary Physician?* No Yes Physician Name, or Practice Name, or None Physican | Practice Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician | Practice PhoneDate Last Seen (approx if you don't know) Reason for visit, findings, treatment (if any) Δ
