Intent to Apply Form - Guide to Life Insurance in the United States©️

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*NameLegal Name/First Last Name

Sexgender

Country/State of BirthBirth Country/State

family addressHome Address (Street, City, State & Zip)

Date of birthDate of Birth

social Security number

Main contact number

Secondary contact number

E-mail address (used for electronic signatures, only US mail service providers can be used)

Are you a US citizen?

State where the driver's license was issued

Driver's license number

Employer name

Position and simple job description

Employment date (mm/dd/yy)

Annual income

Estimated total household assetsUsually larger than the sum assured and insurable

The ownership of the policy is

The insured person

Other individuals

Company

partner

trust

Name of main beneficiary

Address, phone number, and date of birth

social Security number

(Relationship) Is he/she yours?

Claims allocation ratio

Name of Beneficiary

Address, phone number, and date of birth

social Security number

(Relationship) Is he/she yours?

Claims allocation ratio

Does the insured already have annuity, life insurance or disability insurance? Or at the same time, is applying for similar insurance from our company or other companies?

Is the insured person planning to use the policy he is applying for to replace other existing insurance or annuity policies?

In the next two years, does the policyholder intend to travel or live outside the United States or Canada?

In the past 5 years, has the policyholder studied or flew an aircraft, or was a crew member of any aircraft, or intends to perform the above activities in the next two years?

In the past five years, the insured person has engaged in motorsports or racing (cars, trucks, motorcycles, ships, etc.); rock climbing or mountaineering; skin or scuba diving; aviation (glide, skydiving, skydiving, ultralight, high flying, hot Balloon) or have the intention to do so in the next two years?

Did the insurance company modify or adjust the rating, be denied insurance, postpone or withdraw the insurance application when applying for insurance in the past?

Have you filed for bankruptcy protection, or intend to seek bankruptcy protection in the next 12 months?

In the past five years, has it been enough to have his driver’s license revoked, or be charged or convicted for driving under the influence or other illegal driving behaviors?

Was it convicted of a felony or misdemeanor, or is currently imprisoned, released on parole or suspended?

Is the insured person an active U.S. military, a national guard, or a reservist?

Apart from the listed owners or beneficiaries, is there any other party who intends to acquire any rights, ownership or interest in this policy?

Does the policy ownership or policyholder intend to pay for the policy through financing or loan agreements?

During the application process, did you receive payment (cash, services, etc.) from any other person or entity to incentivize this transaction?

Have you participated in any discussion about the possible sale or transfer of this policy to an unrelated third party (such as (but not limited to) a life insurance company or investor group)?

height

weight

In the past 12 months, has there been any significant change in weight?

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Family doctor's name, address, and contact number(If none, please fill in none)

Time of last visit

Reason for the visit & final result(Such as "Normal", "Results need to be observed")

The name, address, telephone number, time of the consultation, the reason and result of the consultation of the specialist in the past 2 years(If none, please fill in none; if there are more than one, please list them separately)

In the past 5 years, have you used any tobacco or nicotine-containing products?

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If yes, fill in the product name, frequency of use, and time of last use(If not, please leave it blank)

In the past 10 years, have you been diagnosed, received treatment, or received prescription medication for the following conditions:

Are there any diseases or abnormalities in the heart, circulatory system, high blood pressure, high cholesterol, arrhythmia, murmur, rheumatic fever, coronary artery disease, chest pain, angina pectoris, transient ischemic attack or stroke?Any disease or abnormal condition of the heart, circulatory system, high blood pressure, high cholesterol, irregular heartbeat, murmur, rheumatic fever, coronary artery disease, chest pain, angina, transient ischemic attack or stroke?

Are there any lung or respiratory diseases, sleep apnea, emphysema, asthma, bronchitis, tuberculosis, shortness of breath, nose or throat allergies or diseases?Any disease of the lungs or respiratory system, sleep apnea, emphysema, asthma, bronchitis, tuberculosis, shortness of breath, allergies or disorder of the nose or throat?

Are there any digestive diseases, including ulcers, chronic indigestion, liver, stomach, intestinal or pancreatic diseases, hepatitis, liver cirrhosis, jaundice, esophagus diseases, gallbladder diseases or colon diseases?Any digestive system disease, including ulcer, chronic indigestion, liver, stomach, intestine or pancreas disorder, hepatitis, cirrhosis, jaundice, esophagus disorder, gallbladder disorder, or colon disorder?

Is there any neurological disease, dizziness, epilepsy, convulsions, paralysis, confusion, brain or eye disease, or headache?Any disorder of the nervous system, dizzy spells, epilepsy, convulsions, paralysis, unconsciousness, brain or eye disorders, or headaches?

Do you have spine, hips, knees, shoulders, back, bones, muscles, arthritis, rheumatism, joints, skin, thyroid, gout or other glandular diseases?Any spine, hip, knee, shoulder, back, bones, muscles, arthritis, rheumatism, joints, skin, thyroid, gout or other gland disorder?

Is there a urinary system disease, including protein, sugar or blood in urine, kidney infection or stones, breast, prostate or bladder or pelvic organ disease or disease?Any urinary system disease including protein, sugar or blood in urine, kidney infection or stones, disorder or disease of the breast, prostate or bladder, or pelvic organs?

Are there any depression, anxiety, bipolar disorder, schizophrenia, attention deficit disorder (ADD) or any other developmental or mental illness, including memory loss, Alzheimer's disease, dementia or post-traumatic stress disorder (PTSD)?Any depression, anxiety, bipolar, schizophrenia, attention deficit disorder (ADD), or any other developmental or psychological condition including memory loss, Alzheimer's, Dementia, or Post Traumatic Stress Disorder (PTSD)?

Any anemia, hemophilia or blood disease other than Acquired Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV)?Any anemia, hemophilia or disorders of the blood other than Acquired Immune Deficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV)?

Acquired immunodeficiency syndrome (AIDS) or AIDS-related syndrome (ARC)?Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?

Diabetes, or high blood sugar?Diabetes or high blood sugar?

Any cancers, polyps and other tumors?Any cancer, polyp, other tumors?

Amputated due to illness or other medical conditions?Amplification due to disease or other medical condition?

Parkinson's disease, muscular dystrophy, Huntington's disease, motor neuron disease, Lou Grieg's disease (ALS) or multiple sclerosis?Parkinson's disease, Muscular Dystrophy, Huntington's Chorea, Motor Neuron Disease, Lou Gehrig's Disease (ALS), or Multiple Sclerosis?

In the past 10 years, have you ever used marijuana, cocaine, heroin or any other illegal drugs or controlled drugs, you should stop or reduce your intake of alcohol or drugs on the advice of your doctor, drugs that are not prescribed by your doctor Or become a member of the organization a support group, such as NA or AA?In the past 10 years have you used marijuana, cocaine, heroin, or any other illicit drug or controlled substance, been advised by a physician to discontinue or reduce alcohol or drug intake, used drugs not prescribed by a physician, or been a member of a support group such as NA or AA?

In the past 5 years, you have consulted with a doctor other than your personal doctor, or underwent X-ray examination, electrocardiogram examination, cardiac catheterization examination or other diagnostic examinations, but does not include examinations for human immunodeficiency virus (AIDS virus) ?Consulted with a physician other than your personal physician or had x-rays, electrocardiograms, heart catheterization or other diagnostic tests, not including tests for exposure to the Human Immunodeficiency Virus (AIDS Virus)?

In the past 5 years, was admitted to the hospital, or was recommended or planned to enter the hospital for any form of observation, surgery or treatment?Been admitted to a hospital, or been advised or plan to enter a hospital for observation, operation or treatment of any kind?

Do you have any appointments with doctors or medical professionals?Do you have any pending appointments with any medical professional?

Have your parents or siblings been diagnosed by a doctor or received treatment for cancer, heart disease, Huntington's disease or polycystic kidney disease?Has a parent or sibling been diagnosed or treated by a health professional for cancer, heart disease, Huntington's Disease or polycystic kidney disease?

Do you currently use or require the use of a wheelchair, walker, multi-branched crutches, hospital bed, dialysis machine, ventilator oxygen, electric cart or stairlift?Use or require the use of a wheelchair, walker, multi-prong cane, hospital bed, dialysis machine, respirator oxygen, motorized cart or stair lift?

Do you now need help, assistance or supervision in the following areas: bathing, eating, dressing, going to the toilet, walking, moving or urinating?Need help, assistance or supervision for: bathing, eating, dressing, toileting, walking, transferring, or maintaining continence?

Do you now need help, assistance or supervision in the following areas: taking medicine, doing housework, washing clothes, shopping or preparing meals?Need help, assistance or supervision in: taking medication, doing housework, laundry, shopping or meal preparation?

Have you ever been diagnosed, treated by a medical professional, tested positive or received medical consultation for the following reasons: fall, paralysis, numbness, tremor, imbalance, or any condition that causes restricted movement?Have you ever been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for: Falls, Paralysis, Numbness, Tremors, Imbalance, or any condition which causes limited motion?

Have you ever been diagnosed, treated by a medical professional, tested positive or received medical consultation for the following reasons: memory loss, confusion, amnesia?Have you ever been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for: memory loss, confusion, amnesia?

Signature｜I understand that the above information is provided voluntarily and is only used by insurance agencies or brokers to help me choose and compare products that meet my own requirements based on this information.Signature | I have understood that the above information is provided voluntarily and is only used by insurance brokerage firms or agent brokers to help me choose and compare products that meet my own requirements based on this information.