Online Term Life Insurance Application
Selected Policy
Insurance Company: West Coast Life Insurance Company
Policy Name: Golden 20 Plus (Oct 1999 / Super Pref.)
Coverage Amount: $500,000
Term Specification: Guaranteed 20 Year Level Term
Health Classification: Preferred Plus
 
 
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Applicant Information
First Name:
Middle Name:
Last Name:
Birthdate:
Gender: MaleFemale
Address:
City:
State:
Zip Code:
Email Address:
Social Security:
Home Phone:
( 213
) 555
- 1212
US Citizen: YesNo
Place of Birth:
Marital Status:
Drivers License:
Drivers License State:
Years at Residence:
 
Previous Address  (if less than 5 years at current)
Address:
City:
State:
Zip Code:
 
Employment Information
Employer:
Position:
Address:
City:
State:
Zip Code:
Years with Company:
Work Phone:
( 213
) 555
- 1212
  ext.  1234
 
Primary Beneficiaries
The person(s) designated to receive the death benefit if the insured dies.
Name Relationship %
 
Contingent Beneficiaries
The person(s) designated to receive the death benefit if the primary
beneficiaries are deceased when the insured dies.
Name Relationship %
 
Policy Owner  (if not the person to be insured)
Owner's Name:
Address:
City:
State:
Zip Code:
SSN or Tax ID:
Relationship:
Owner Type:
Birthdate or Company Formation Date:
Phone:
( 213
) 555
- 1212
  ext.  1234
 
Existing Life Insurance Information
Insurance Company Policy Number Coverage Amount Year Issued Replacing?
$ YesNo
$ YesNo
$ YesNo
$ YesNo
 
Immediate Family Medical History
Age if Living Age of Death Present Health/Cause of Death Cancer History Circulatory Disease Age of Onset
Father YesNo YesNo
Mother YesNo YesNo
Brother YesNo YesNo
Brother YesNo YesNo
Brother YesNo YesNo
Sister YesNo YesNo
Sister YesNo YesNo
Sister YesNo YesNo
 
Medical Questions
Do you have a personal physician?  YesNo
Physician's First Name:
Physician's Last Name:
Physician's Address:
Physician's City:
Physician's State:
Physician's Zip Code:
Physician's Phone:
( 213
) 555
- 1212
  ext.  1234
Last Visit:
Reason for Last Visit:
Treatment:
Your Height:
ft.
  in.
Your Weight:  lbs.
List Prescription drugs
taken in the last year:

Have you ever been treated for the following?  Select all that apply.  
Circulatory System Central Nervous System Respiratory System Digestive System
Anemia
Angina
Arrhythmia
Heart Attack
Heart Disease
Heart Murmur
Heart Surgery
High Blood Pressure
High Cholesterol
Leukopenia
Palpitations
Phlebitis
Polycythemia
Vascular Disease
Alzheimer's
Epilepsy
Dizziness
Fainting
Head Injury
Migraines
Mult. Sclerosis
Other
Paralysis
Stroke
Asthma
Bronchitis (chronic)
Emphysema
OtherResp
Pneumonia
Tuberculosis
Colitis
Chronic Diarrhea
Diverticulitis
Esophagus
Hepatitis
Ileitis
Internal Bleeding
Intestinal Problem
Liver Disease
Rectal Problem
Stomach Disorder
Ulcers
Urinary System Skin, Bones and Muscles Infections Mental Health
Abnormal Pap
Albumin
Bladder Disease
Blood
Kidney Disease
Kidney Stone
Neurogenic Bladder
Prostate Disease
Protein
Pus in Urine
Sugar
Arthritis
Bone Disease
Gout
Muscle Disorder
Neuritis
HIV
Sexually Transmitted Disease
Anxiety
Depression
Mental Disorder
Nervous Problem
Other
Metabolism Problems Cancer Other Medical Disorders Drug & Alcohol Abuse
Diabetes
Endocrine Glands
Pituitary Gland
Thyroid
Bladder
Breast
Cervical
Colon
Hodgkin's Disease
Melanoma
Other
Prostate
Skin
Ears
Eyes
Nose
Throat
Alcohol Treatment
Alcoholics Anonymous
Cocaine
Drug Treatment
Hallucinogenics
Heroin
Narcotics
Narcotics Anonymous
Other

Do you have any medical appointments scheduled in the next 4 months? YesNo
Have you received medical treatment at a treatment center in the last 5 years? YesNo
Have you ever had any mental disorder not covered above? YesNo
Have you ever had any physical disorder not covered above? YesNo
Have you been advised to have surgery in the last 5 years? YesNo
Have you been advised to have a medical X-ray, EKG, or other medical test in the last 5 years? YesNo
Briefly explain each 'Yes" answer in the Medical section above:
 
General and Lifestyle Questions
Have you ever used any tobacco or nicotine product?
Date last used:
x
Have you worked in a hazardous occupation in the last 3 years? YesNo
Have you participated in any of the following activities during the past 3 years?     Ballooning, competitive skiing, hang gliding, mountain climbing, powered racing, rodeo, skuba diving, skydiving , soaring, ultralight. YesNo
Have you ever been declined for life insurance?     Or had your premium increased during the application process? YesNo
Do you have any other life insurance applications in process? YesNo
Have you ever been convicted of a felony or a misdemeanor (other than traffic violations)? YesNo
Are you a member of the military or reserves? Do you intend to be? YesNo
Have you ever applied for and/or received disability income, Social Security, or Worker's Comp payments? YesNo
Have you flown as a pilot or crew in the last 3 years? YesNo
Are you a US resident for less than 3 years? YesNo
Do you have foreign travel plans in the next 2 years? YesNo
Have you been found guilty of driving under the influence or reckless driving? YesNo
Have you been found guilty of three or more traffic violations? YesNo
Have you ever had your driving privileges taken away by the courts? YesNo
Briefly explain each 'Yes" answer in the General and Lifestyle section:
 
Personal Life Insurance Financial Information  (skip if business insurance)
Purpose of Insurance: Survivor Needs  Estate Planning  Mortgage Protection
Other 
Yearly Income: $
Estimated Net Worth: $
Have you had any liens or judgments filed against you or filed for bankruptcy in the last 5 years? YesNo
 
Business Life Insurance Financial Information  (skip if individual insurance)
Purpose of Insurance: Buy Sell  Split Dollar
Deferred Compensation  Keyman
Other 
Total Assets: $
Total Liabilities: $
Net Worth: $
% of business you own: %
How much business life insurance is in force on your life? $
Has business life insurance been applied for or in force on other key members of the business? YesNo
Have you had any liens or judgments filed against you or filed for bankruptcy in the last 5 years? YesNo
 
Premium Information
Frequency of premium payments?
Note: annual payments provide for the lowest premiums.
Note: monthly payments are by automatic bank debit.
If premium notices are to be sent to someone other than Owner, please enter the following information on that person.  
First Name:
Middle Name:
Last Name:
Address:
City:
State:
Zip Code:
Relationship:
 
Medical Exam Appointment
For your convenience, select a time and place
for your free 20 to 30 minute medical exam.
Please input Day & Date:
Time:  
Location:  HomeWork
 
 
 
 


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