WL Final Expense Application

Secure application – we’ll review, confirm over the phone and submit to our underwriter.

1. Client information

2. Beneficiaries, personal history & payment

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

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?

Mailing Street Address

Apartment/Unit (optional)

City

State

ZIP Code

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/Territory (if U.S.)

Driver's License / ID #

DL State

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

Coverage Start & Payment

When would you like to start?

Preferred monthly draft date:

Payment method

Additional fees may apply for card payments.

Financial institution

Routing number

Account number

Card number

Expiration (MM/YY)

Cvv#

Billing ZIP

Health Questions (needed to help you qualify for the least expensive plan)

Have you ever been diagnosed, treated, tested positive for, or been given medical advice for: (Select all that apply)

A condition requiring a defibrillator

More info (when, why, current status, as needed)

Alzheimer’s Disease, Dementia, memory loss, or mental incapacity

More info (when, why, current status, as needed)

Amputation, not due to trauma

More info (when, why, current status, as needed)

Amyotrophic Lateral Sclerosis (ALS) or Lou Gehrig’s disease

More info (when, why, current status, as needed)

Cerebral Palsy

More info (when, why, current status, as needed)

Cystic or Pulmonary Fibrosis

More info (when, why, current status, as needed)

Down’s Syndrome

More info (when, why, current status, as needed)

Huntington’s Disease

More info (when, why, current status, as needed)

Metastatic cancer, recurrent cancer, or cancer of multiple sites

More info (when, why, current status, as needed)

Organ transplant or bone marrow recipient

More info (when, why, current status, as needed)

Sickle Cell Anemia, hydrocephalus

More info (when, why, current status, as needed)

None of the above

Are you currently: (Select all that apply)

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?

More info (when, why, current status, as needed)

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

More info (when, why, current status, as needed)

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

More info (when, why, current status, as needed)

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

More info (when, why, current status, as needed)

None of the above

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

More info (details needed - dates, current status, what meds, treatment)

In the past 2 years, have you attempted suicide?

Yes No

More info (details needed - dates, current status, what meds, treatment)

Have you ever been diagnosed, treated, tested positive for, or been given medical advice for: (Select all that apply)

Cancer, leukemia, melanoma or any other internal cancer - excluding basal or squamous cell carcinoma

More info (when, why, current status, as needed)

Congestive heart failure (CHF) or cardiomyopathy

More info (when, why, current status, as needed)

Cirrhosis, liver failure, chronic pancreatitis, Hepatitis C

More info (when, why, current status, as needed)

Systemic lupus, scleroderma

More info (when, why, current status, as needed)

Multiple Sclerosis

More info (when, why, current status, as needed)

Muscular Dystrophy, Myelodisplastic Syndrome (MDS), Quadriplegia, Paraplegia

More info (when, why, current status, as needed)

Parkinson's Disease

More info (when, why, current status, as needed)

Severe asthma or COPD, including emphysema, sarcoidosis, chronic bronchitis, chronic lung disease,

More info (when, why, current status, as needed)

None of the above

In the past 4 years, have you been diagnosed, treated, tested positive for, or been given medical advice for: (Select all that apply)

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)

More info (when, why, current status, as needed)

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

More info (when, why, current status, as needed)

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

More info (when, why, current status, as needed)

Liver disease or disorder or Hepatitis, excluding Hepatitis A

More info (when, why, current status, as needed)

None of the above

In the past 2 years, have you been diagnosed, treated, tested positive for, or been given medical advice for: (Select all that apply)

Cardiac surgery - examples may include pacemaker, stent, valve, bypass, angioplasty, valvular heart disease with surgical repair or replacement, any heart or circulatory disorder

More info (when, why, current status, as needed)

Heart attack

More info (when, why, current status, as needed)

Kidney (renal) disease or failure, or a condition requiring dialysis

More info (when, why, current status, as needed)

Prescribed supplemental oxygen, consulted a physician for chronic cough, unexplained weight loss greater than 10 pounds, fatigue or unexplained gastrointestinal bleeding

More info (when, why, current status, as needed)

Stroke, transient ischemic attack (TIA), cerebrovascular accident (CVA), aneurism, brain tumor

More info (when, why, current status, as needed)

None of the above

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

More info (details needed - dates, current status, what meds, treatment)

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

More info (details needed - dates, current status, what meds, treatment)

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

Yes No

More info (details needed - dates, current status, what meds, treatment)

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

More info (details needed - dates, current status, what meds, treatment)

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 Information

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

Examples: cigarettes, e-cigarettes, vape(s), 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

More info (details needed - dates, current status, what meds, treatment)

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

More info (details needed - dates, current status, what meds, treatment)

In the past 2 years, have you used ulawful 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

More info (details needed - dates, current status, what meds, treatment)

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

More info (details needed - dates, current status, what meds, treatment)

Anything else we should know?

Primary care doctor information (name, clinic, phone)

Prescription medications and reasons for taking them (required)

Anything else you want us to consider with your 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.

We’ll review this with you by phone before submitting to our underwriter.