1.   First Name:    

    1a. Last Name:

2.     Sex:    Male: Female:

3.    Date of Birth:   

4.    Check if a concurrent application is being submitted on: Spouse: Business partner:

        4a.    Name's of the above:

5.    Amount of Insurance:    5a. Type of insurance: Term Life Whole Life

       5b.  Term Duration: 30 years 15 years 10 years 5 years 25 years 20 years

6.    Is this policy replacing a current policy:Yes: No:

        6b.     If yes provide exact details on the in-force Insurance:        

7.    Tobacco Use:

Cigarettes, Cigars, Pipe's, Chewing or snuff, Nicotine gum, Nicotine patch or Medicine

    7a.    Currently using:Yes:     Never Used:Yes:      Past User:Yes:

    7b.    Have not used last: 6 months: 12 months: 24 months: 36months: 48months:

8.    Family History: Check all that applies to family members diagnosed Prior to age 60

9.      Are you a pilot, other than as a commercial airline pilot?

         Yes: No:

10.    Do you engage in Hazardous avocation such as:

         auto racing: scuba diving:    mountain climbing:

11.    Have you had more than 2 moving traffic violations in the past 3 years?

         Yes: No:

12.    What medications do you take?

13.    Give details of any significant medical history or conditions.

14.    Current Weight:

15.   Height in inches please:    

Name of Person completing this form:

Day Phone:

Evening Phone:

E-mail address: