North Carolina Life Insurance Application Questions

ALLCHOICE Agent Information

Select Your Advisor*

INSURED INFORMATION

Proposed Insured*

First Last

Maiden (If Applicable)

Date Of Birth

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

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?

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

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?

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

PURPOSE OF INSURANCE

Check All That Apply

Income Replacement (Personal)
Estate Planning (Personal)
Creditor (Personal)
Key Man (Business)
Buy-Sell (Business)
Creditor (Business)

Approximate Annual Income (Business or Personal)

Estimated Net Worth (P) or Business Value (B)

In the past 5 years has the proposed insured filed for bankruptcy or had any liens/judgements filed against him/her?

Yes
No

Has the bankruptcy been discharged or lien/judgement satisfied?

Yes
No

Provide date of discharge

Details

PAPERLESS DELIVERY

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?

Yes
No