Final Expense Insurance Pre-Approval SHORT APPLICATION

Secure Pre-Approval SHORT APPLICATION review. We will confirm your answers by phone before anything is submitted to a carrier.

1. Client information

2. Beneficiaries, health history & final details

Client Information

Coverage amount requested

Expected premium (verify with your agent)

Insured – legal name (must match Driver’s License or ID).

First Name

Middle Name

Last Name

Suffix

Does the insured already have any life insurance coverage?

Yes No

Gender

Date of Birth

Height

Weight (lbs)

Mobile number

Email Address

INSURED: Physical Residential Address

No P.O. boxes please.

Street Address

Apartment/Unit (optional)

City

State

ZIP Code

Mailing address different from physical address?

Beneficiaries

Enter your beneficiaries and make sure the split adds up to 100%. You can add primary, equal split, and contingent.

Contingent beneficiaries receive benefits if all primary beneficiaries have passed away before the insured.

Name

DOB

Relationship

Split %

Type

Split must equal 100%.

Are you - the Insured - a U.S. Citizen or Permanent Resident?

Yes No

Place of Birth

Country

State of Birth

Driver's License / ID # I don't have a driver's license or state ID.

DL State

DL / ID Expiration Date

Health History Questions

Please answer each question as accurately as you can. These answers help us match you with an appropriate carrier and avoid submitting to a plan that is unlikely to approve. A Yes answer does not always mean you cannot qualify.

Have you ever been diagnosed, treated, tested positive for, or been given medical advice for: (Please answer each item)

Are you currently: (Please answer each item)

Bedridden, or requiring assistance with any activities of daily living such as: taking medications, bathing, dressing, eating, toileting, getting in and out of a chair or bed, or control of bowel or bladder problems?

Yes No

Incarcerated or on probation or parole due to a conviction or guilty plea

Yes No

Residing in a hospital, nursing home, assisted living, long-term care or skilled nursing facility

Yes No

Receiving or advised to receive hospice care, palliative, or home health care

Yes No

Has a licensed member of the medical profession indicated that your life expectancy is 12 months or less due to a terminal medical condition, or recommended you be added to a transplant list?

Yes No

In the past 2 years, have you attempted suicide?

Yes No

Have you ever been diagnosed, treated, tested positive for, or been given medical advice for: (Please answer each item)

In the past 4 years, have you been diagnosed, treated, tested positive for, or been given medical advice for: (Please answer each item)

Diabetes before age 45, or diabetes with any of the following: insulin treatment, peripheral vascular disease, neuropathy (nerve), amputation, retinopathy (eye), nephropathy, kidney disease, end-stage renal disease; insulin shock, diabetic coma or Peripheral Vascular Disease (PVD or PAD)

Yes No

Bipolar depression, Schizophrenia, Inpatient treatment as a result of a mental or nervous disorder

Yes No

Irregular heart beat (arrhythmia), atrial fibrillation, coronary artery disease (CAD), coronary artery bypass, angina (cardiac chest pain), heart disease, heart attack, heart surgery or un-operated heart defects

Yes No

Liver disease or disorder or Hepatitis, excluding Hepatitis A

Yes No

In the past 2 years, have you been diagnosed, treated, tested positive for, or been given medical advice for: (Please answer each item)

Have you ever tested positive for exposure to the HIV infection or been diagnosed as having ARC or AIDS or any condition derived from such infection?

Yes No

In the past 12 months, have you been confined to a wheelchair or electric scooter for assistance (other than a temporary injury or treatment not exceeding 3 months)?

Yes No

In the past 12 months, have you spent 2 or more nights in the hospital (excluding childbirth)?

Yes No

In the past 12 months, have you been advised to have any tests, procedure, surgery, or hospitalization which have not been completed, or are you waiting for a medical diagnosis or results?

Yes No

In a typical week, how many days do you perform intentional physical activity for at least 10 consecutive minutes?

Examples: yard work, walking, exercising, sports.

0 days per week 1 day per week 2 days per week 3 days per week 4 days per week 5 days per week 6 days per week 7 days per week

Lifestyle & Tobacco History

When was the last time you used tobacco or a nicotine product?

Examples: cigarettes, e-cigarettes, vaping, pipe, hookah/water pipe, chewing or smokeless tobacco, cigars, nicotine patch or gum.

In the past 2 years, have you been convicted of or pleaded no contest to reckless driving or operating while intoxicated (DWI/OWI/DUI)?

Yes No

In the past 2 years, have you been convicted of or pleaded no contest to a felony or do you have such charges currently pending against you?

Yes No

In the past 2 years, have you used unlawful drugs in any form, abused or misused sedatives, amphetamines, barbiturates, opiates, or any hallucinogenic or narcotic drug, except as prescribed by a licensed member of the medical profession?

Yes No

In the past 2 years, have you been treated, counseled, or advised to seek treatment or counseling by a licensed member of the medical profession, for alcohol or drugs or joined an organization for dependence or abuse?

Yes No

Anything else we should know?

Primary care doctor information (name, clinic, phone)

Prescription medications and reasons for taking them (required)

Anything else you would like us to consider with this Pre-Approval SHORT APPLICATION

Electronic Signature

Use your finger (on phone/tablet) or mouse (on computer) to sign your name below.

By signing, you agree this is your electronic signature.

Final Verification & Initial Payment Method

These details help the carrier prepare the application and help protect the rate you requested if you are approved. You can provide them here, or we can finish any sensitive items with you by phone.

U.S. Social Security Number You may provide full SSN now or by phone. Prefer to provide by phone

If approved, when would you like coverage to start? This is not a promise of approval. It simply tells us how to line things up if the carrier approves the application.

Preferred monthly draft date

Payment method

Providing a payment method now can help avoid delays if approved. Card payments are not always accepted and may have extra fees.

Prefer to provide by phone

Financial institution

Routing number

Account number

We will review this with you by phone before submitting to a carrier. Coverage is not in force unless and until approved by the carrier and the first premium is paid.