North Carolina Life Insurance Application Questions

Name: ALLCHOICE Insurance
Price range: $

ALLCHOICE Agent Information
Select Your Advisor*
INSURED INFORMATION
Proposed Insured*
First Last
Maiden (If Applicable)
Date Of Birth
MM slash DD slash YYYY
Gender
- Female
- Male
Social Security Number
Height
Weight
CONTACT INFORMATION
Address
Street Address City State ZIP Code
No. of Years at this address?
Email
Mobile Phone
Best Time To Call
Birth Country
Country
State of Birth
State
Marital Status
Do 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?
Employer Name
Employer Address
Street Address City State ZIP Code
Occupation
Duties
No. of Years at Employer
Employer Phone
BENEFICIARIES
Primary Beneficiary
First Last
Beneficiary Address
Street Address City State ZIP Code
Relation To Insured
Beneficiary Date Of Birth
MM slash DD slash YYYY
Beneficiary Social (if you have it)
Beneficiary Notes
State if more than 1 Beneficiary or if you want to include Contingent Beneficiary (complete the form then discuss with your agent)
OTHER COVERAGE INFORMATION
Is the policy applied for intended to replace any existing life insurance or annuity policies with this or any other company?
Explanation
Explain why you are replacing the current contract
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?
Current Life Insurance Carrier
If more than 1 - please list all separated by a comma
Current Life Insurance Coverage Amount
If more than 1 - please list all separated by a comma
Current Life Insurance Policy Number(s)
If more than 1 - please list all separated by a comma
Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract?
Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract?
Would you like the State Replacement Notice read aloud?
PLAN INFORMATION
Proposed Insured Face Amount (Death Benefit)
Purpose Of Insurance
Optional Benefit Riders (check to include)
- Waiver of Premium
- Children's Term Rider
Premium Mode
Send Premium Notices to:
Other Address
Street Address City 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 issue
Name on Account
Name of Bank
Type Of Account
Account 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.
NON-MEDICAL UNDERWRITING
Has the proposed insured applied for or received disability benefits in the last 5 years?
- Yes
- No
If Yes, explain
Has the proposed insured applied for life or health insurance that was declined, postponed, or modified, or had reinstatement of an insurance policy denied?
- Yes
- No
If Yes, explain
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?
- Yes
- No
If Yes, Explain
Has the proposed insured had more than 2 moving motor vehicle violations in the last 3 years?
- Yes
- No
If yes, Explain
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?
- Yes
- No
If yes, Explain
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?
- Yes
- No
If yes, Explain
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?
- Yes
- No
If yes, Explain
Include the following: 1. Destination 2. Date (Start & End) 3. Purpose (Example - Vacation / Business / Etc)
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?
- Yes
- No
If yes, Explain
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?
- Yes
- No
If yes, Explain
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?
- Yes
- No
If yes, Explain
Is the proposed insured a US or Canadian citizen or permanent US Resident
- Yes
- No
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)?
- Yes
- No
Details (Current Smoker? Past Smoker? if past - include date quit)
Have you ever used smokeless tobacco?
- Yes
- No
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?
- Yes
- No
Details (include "what", if current...if past include date of last use)
PRIMARY PHYSICIAN
Do You Have A Primary Physician?
- No
- Yes
Physician Name, or Practice Name, or None
Physican | Practice Address
Street Address City State ZIP Code
Physician | Practice Phone
Date Last Seen (approx if you don't know)
Reason for visit, findings, treatment (if any)
MEDICAL & SUPPLEMENTAL QUESTIONS
Do You Want To Answer Medical Questions NOW?*
Are You Applying For The Supplemental Long Term Care Rider?*
MEDICAL HISTORY
Does the Proposed Insured have a family history (parents) of heart disease, stroke or cancer other than basal cell carcinoma?
- No
- Yes
Father
Is Your Father Still Alive
Please list health condition and date of onset - Father
Mother
Is Your Mother Still Alive
Please list health condition and date of onset - Mother
In Past 5 Years Has The Insured:
Used any controlled substance, such as cocaine, heroin, narcotics, amphetamines, barbiturates, sedatives, hallucinogens, or marijuana without a medical prescription?
- No
- Yes
Details Of Impairment/Condition
Dates (From - To)
Complete Recovery
- Yes
- No
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address Address Line 2 City State ZIP Code
Physician / Facility Phone
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?
- No
- Yes
Details Of Impairment/Condition
Dates (From - To)
Complete Recovery
- Yes
- No
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
Physician / Facility Phone
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:
Fainting spells, severe headaches, paralysis, stroke, epilepsy, depression or other mental illness or any disease or disorder of the brain or nervous system?
- No
- Yes
Details Of Impairment/Condition
Dates (From - To)
Complete Recovery
- Yes
- No
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
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?
- No
- Yes
Details Of Impairment/Condition
Dates (From - To)
Complete Recovery
- Yes
- No
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
Physician / Facility Phone
Any disease or disorder of the stomach, esophagus, colon, intestines, liver, glands or digestive system?
- No
- Yes
Details Of Impairment/Condition
Dates (From - To)
Complete Recovery
- Yes
- No
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
Physician / Facility Phone
High blood pressure, chest pain, heart attack, heart murmur, anemia, or any disease or disorder of the blood, heart or circulatory system?
- No
- Yes
Details Of Impairment/Condition
Dates (From - To)
Complete Recovery
- Yes
- No
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
Physician / Facility Phone
Diabetes, kidney disease or disorder, or sugar, albumin, or blood in the urine?
- No
- Yes
Details Of Impairment/Condition
Dates (From - To)
Complete Recovery
- Yes
- No
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
Physician / Facility Phone
Arthritis, lupus, or any disease or disorder of the back, bones, joints or muscles?
- No
- Yes
Details Of Impairment/Condition
Dates (From - To)
Complete Recovery
- Yes
- No
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
Physician / Facility Phone
Cancer, leukemia, tumor, or polyp?
- No
- Yes
Details Of Impairment/Condition
Dates (From - To)
Complete Recovery
- Yes
- No
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
Physician / Facility Phone
Any sexually transmitted disease (STD)?
- No
- Yes
Details Of Impairment/Condition
Dates (From - To)
Complete Recovery
- Yes
- No
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
Physician / Facility Phone
Any impairment of hearing or sight, except for the need of corrective lenses?
- No
- Yes
Details Of Impairment/Condition
Dates (From - To)
Complete Recovery
- Yes
- No
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
Physician / Facility Phone
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)?
- No
- Yes
Details Of Impairment/Condition
Dates (From - To)
Complete Recovery
- Yes
- No
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
Physician / Facility Phone
A weight loss of 15 pounds or more in the past 12 months (except for pregnancy-related weight loss)?
- No
- Yes
Details Of Impairment/Condition
Dates (From - To)
Complete Recovery
- Yes
- No
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
Physician / Facility Phone
Is the Proposed Insured now pregnant?
- No
- Yes
Expected Due Date
MM slash DD slash YYYY
Has the Proposed Insured been prescribed or taken any medication in the last 12 months?
- No
- Yes
Details Of Impairment/Condition
Dates (From - To)
Complete Recovery
- Yes
- No
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
Physician / Facility Phone
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?
- No
- Yes
Details Of Impairment/Condition
Dates (From - To)
Complete Recovery
- Yes
- No
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
Physician / Facility Phone
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?
- No
- Yes
Details Of Impairment/Condition
Dates (From - To)
Complete Recovery
- Yes
- No
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
Physician / Facility Phone
Has the Proposed Insured been advised to have or contemplated having a surgical operation that has not been done?
- No
- Yes
Details Of Impairment/Condition
Dates (From - To)
Complete Recovery
- Yes
- No
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
Physician / Facility Phone
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?
- No
- Yes
Details Of Impairment/Condition
Dates (From - To)
Complete Recovery
- Yes
- No
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
Physician / Facility Phone
SUPPLEMENTAL MEDICAL HISTORY (FOR LTC RIDER)
Are You Covered By Medicaid? (Note This Does NOT Mean Medicare)
- No
- Yes
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?
- No
- Yes
Reason And Company
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?
- No
- Yes
Details
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?
- No
- Yes
Details
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?
- No
- Yes
Details
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?
- No
- Yes
Details & Diagnosis
Date Of Onset
Treatments And/Or Medications Prescribed
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
Physician / Facility Phone
Have you been diagnosed or treated by a member of the medical profession, been prescribed or taken medication for:
Alzheimer’s disease, dementia, recurrent or chronic memory loss, mild cognitive impairment (MCI) or organic brain syndrome?
- No
- Yes
Details & Diagnosis
Date Of Onset
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
Physician / Facility Phone
Multiple sclerosis, Parkinson’s disease, stroke or Transient Ischemic Attack (TIA), muscular dystrophy or ALS (Lou Gehrig’s disease)?
- No
- Yes
Details & Diagnosis
Date Of Onset
Attending Physician / Facility - Same As Regular Physician / Facility?
- Yes
- No
Physician Name Or Medical Facility
Physician / Facility Address
Street Address City State ZIP Code
Physician / Facility Phone
Any disorder or disease requiring the use of narcotic or opioid pain medications?

North Carolina Life Insurance Application Questions

ALLCHOICE Agent Information

INSURED INFORMATION

CONTACT INFORMATION

BENEFICIARIES

OTHER COVERAGE INFORMATION

PLAN INFORMATION

BANK INFORMATION

NON-MEDICAL UNDERWRITING

TOBACCO AND NICOTINE USE

PRIMARY PHYSICIAN

MEDICAL & SUPPLEMENTAL QUESTIONS

MEDICAL HISTORY

In Past 5 Years Has The Insured:

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:

SUPPLEMENTAL MEDICAL HISTORY (FOR LTC RIDER)

Have you been diagnosed or treated by a member of the medical profession, been prescribed or taken medication for: