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SECURE FORM


You're applying for $ Benefit, expected premium is $ mo.

[click to EDIT amount or age/gender]

READY TO START COVERAGE ?
Complete the APPLICATION below

(Prefer TELEPHONE APPLICATION? Call (321) 300-1446 )

Coverage starts after underwriting approval of your rate. You will receive a policy by mail. A telephone call with the Underwriter may be necessary before approval. NO MEDICAL EXAM needed for benefits up to $40,000. Over $40,000 it's possible to need physical measurements and urine sample/test, possibly a blood test needed depending on your age, benefit amount applied for and time since last Dr. visit.


Customer Satisfaction Guarantee: you have 30 days to receive full refund, if the coverage does not satisfy your needs. After the first 30 days, you may cancel at any time and coverage will stop at your request. Otherwise, your coverage will last for the life of the policy and premiums will never increase during that time.

Name a BENEFICIARY


Where should we mail the policy? (no P.O. boxes)


INSURED information:


Medical questions - INSURED

NO MEDICAL EXAMS! Just answer a few health history questions.

(any "Yes" answers will NOT disqualify you from being approved!).

Check all that apply:









Primary physician information


Premium payment information

Call for rates first, if not sure how much your expected premium will be: (321) 300-1446

(Credit/debit card payment is NOT available on all plans)

Additional info, comments:

Feel free to ask a question or leave a comment. Use this field for additional beneficiaries, list additional health issues

Signature:


After you click SUBMIT APPLICATION above, an underwriter will review and contact you if needed to confirm any information provided on your application. After all info is confirmed, a policy may be expected to be mailed to INSURED or PAYOR.