感謝您與我們聯繫。 我們會盡快回复您。 11https://thelifetank.com/wp-content/plugins/nex-forms-express-wp-form-builder假信息https://thelifetank.com/wp-admin/admin-ajax.phphttps://thelifetank.com/zh-tw/demo-applyform是1淡入淡出 *姓名Legal Name / First Last Name性別性別- - 選擇 - -男女出生國家/ 州Birth Country / State家庭地址Home Address(Street, City, State & Zip)出生年月日出生日期社會安全號碼主要聯絡電話次要聯絡電話電子郵件地址(用於電子簽名,只能使用美國郵件服務商)是美國公民嗎?是否駕照簽發的州駕照號碼雇主名稱職位及簡單工作描述僱傭日期(mm/dd/yy)年收入家庭資產總值預估通常大於保額具備可保性保單的所有權是投保人本人其他個人公司合夥人信任度 下一步:受益人資訊 主要受益人名稱地址,電話,及出生年月日社會安全號碼(關係)他/她是您的?理賠金分配比例順位受益人名稱地址,電話,及出生年月日社會安全號碼(關係)他/她是您的?理賠金分配比例 上一頁 下一頁 投保人是否已經有年金,人壽保險或傷殘保險? 或與此同時,正在申請本公司或其他公司的同類保險?是否投保人是夠打算用正在申請的保單,來取代現有的其他保險或年金保單?是否在接下來的兩年內,投保人打算在美國或加拿大以外旅行或居住嗎?是否在過去5年裡,投保人學習或駕駛飛機,或曾是任何飛機的機組成員,或打算在接下來的兩年內做出上述活動?是否在過去的五年中,投保人從事賽車運動或賽車(汽車,卡車,摩托車,輪船等); 攀岩或登山; 皮膚或水肺潛水; 航空(滑翔,跳傘,跳傘,超輕,高飛,熱氣球)或具有未來兩年有意這樣做嗎?是否有沒有過去投保時,被保險公司修改或調整評級,被拒保,推遲或撤回保險申請的行為?是否是否申請過破產保護,或有意在接下來的12個月內尋求破產保護?是否在過去的五年中,是夠被吊銷駕照,或因酒後駕車或其他違法駕駛行為被指控或被定罪?是否是否被判重罪或輕罪,或目前被監禁,假釋或緩刑?是否投保人是美國現役軍人,國名警衛隊,或預備役人員嗎?是否除列出的所有者或受益人外,是否有其他任何一方有意獲得此保單中的任何權利,所有權或權益?是否保單所有權或投保人是否打算透過融資或貸款協議來支付此保單?是否在申請過程中,是否收到來自任何其他個人或實體的付款(現金,服務等),以激勵進行此交易?是否您是否參與過有關此保單可能出售或轉讓給無關的第三方(例如(但不限於)人壽保險公司或投資者集團)的任何討論?是否 上一頁 下一步:「免體檢」申請問答(Optional) 身高體重在過去的12個月裡,體重有沒有明顯的變化?有沒有家庭醫生姓名,地址,及聯絡電話(如無,請填寫無)最後一次拜訪的時間拜訪的原因& 最後的結果(如「正常」,「結果需繼續觀察」)過去2年內就診的專科醫生姓名,地址,聯絡電話,看診時間,以及看診原因及結果(如無,請填寫無;如有多個,請具體分別列出)在過去的5年裡,使用過任何煙草或含尼古丁的產品?有沒有如果有,填寫產品名稱,使用頻率,最後一次使用的時間(如無,請留空白)在過去的10年裡,對於下面的情況,你是否被確診過,或接受治療,或接受處方葯治療:心臟,循環系統,高血壓,高膽固醇,心律不齊,雜音,風濕熱,冠狀動脈疾病,胸痛,心絞痛,短暫性腦缺血發作或中風有任何疾病或異常嗎?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, transattient is icocke是否是否有任何肺部或呼吸系統疾病,睡眠呼吸暫停,肺氣腫,氣喘,支氣管炎,肺結核,呼吸急促,鼻子或喉嚨過敏或疾病?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?是否有沒有消化系統疾病,包括潰瘍,慢性消化不良,肝,胃,腸或胰臟疾病,肝炎,肝硬化,黃疸,食道疾病,膽囊疾病或結腸疾病?Any digestive system disease, including ulcer, chronic indigestion, liver, stomach, intestine or pancreas disorder, hepatitis, cirrhosis, jaundice, esophagus disorder, gallbladder disorder, or colon disorder?是否是否有神經系統疾病,頭暈目眩,癲癇,抽搐,癱瘓,神智不清,大腦或眼部疾病或頭痛?Any disorder of the nervous system, dizzy spells, epilepsy, convulsions, paralysis, unconsciousness, brain or eye disorders, or headaches?是否是否有脊椎,臀部,膝蓋,肩膀,背部,骨骼,肌肉,關節炎,風濕病,關節,皮膚,甲狀腺,痛風或其他腺體疾病?Any spine, hip, knee, shoulder, back, bones, muscles, arthritis, rheumatism, joints, skin, thyroid, gout or other gland disorder?是否是否有泌尿系統疾病,包括蛋白質,尿液中的糖或血液,腎臟感染或結石,乳房,前列腺或膀胱或骨盆器官的疾病或疾病?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?是否是否有任何抑鬱症,焦慮症,躁鬱症,精神分裂症,注意力缺陷障礙(ADD)或任何其他發展或心理疾病,包括記憶力減退,阿爾茨海默氏病,癡呆症或創傷後應激障礙(PTSD)?Any depression, anxiety, bipolar, schizophrenia, attention deficit disorder (ADD), or any other developmental or psychological condition including memory loss, Alzheimer's, Dementia, ororder Post Traumatic Stress Disorderer's, Dementia, ororder Post Traumatic St.是否心臟,循環系統,高血壓,高膽固醇,心律不齊,雜音,風濕熱,冠狀動脈疾病,胸痛,心絞痛,短暫性腦缺血發作或中風有任何疾病或異常嗎?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, transattient is icocke是否除獲得性免疫缺陷綜合症(AIDS),人類免疫缺陷病毒(HIV)以外的任何貧血,血友病或血液疾病?Any anemia, hemophilia or disorders of the blood other than Acquired Immune Deficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV)?是否獲得性免疫缺陷症候群(AIDS)或AIDS相關綜合症(ARC)?Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?是否糖尿病,或高血糖?Diabetes or high blood sugar?是否任何癌症,息肉和其他腫瘤?Any cancer, polyp, other tumors?是否因疾病或其他醫療狀況而截肢?Amputation due to disease or other medical condition?是否帕金森氏症,肌肉營養不良,亨廷頓舞蹈症,運動神經元疾病,婁格里格氏症(ALS)或多發性硬化症?Parkinson's disease, Muscular Dystrophy, Huntington's Chorea, Motor Neuron Disease, Lou Gehrig's Disease (ALS), or Multiple Sclerosis?是否在過去的10年中,您是否曾使用過大麻,可卡因,海洛因或任何其他非法藥物或管製藥物,在醫生的建議下應停止或減少酒精或藥物的攝入量,未由醫生處方的藥物或成為該組織的成員一個支持小組,例如NA或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 drugs, a support group such as NA or AA?是否在過去的5年中,向您的私人醫生以外的醫生諮詢過,或者進行了X光檢查,心電圖檢查,心臟導管檢查或其他診斷檢查,但不包括接受人類免疫缺陷病毒(AIDS病毒)的檢查?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 (not including tests for exposure to the Human Immunodeficiency Virus (AIDSiciency Virus (AIDSici)?是否在過去的5年中,被送進醫院,或被建議或計劃進入醫院進行任何形式的觀察,手術或治療?Been admitted to a hospital, or been advised or plan to enter a hospital for observation, operation or treatment of any kind?是否您是否有任何和醫生或醫療專業人員的預約看診?Do you have any pending appointments with any medical professional?是否父母或兄弟姊妹是否被醫生診斷為或接受了癌症,心髒病,亨廷頓舞蹈症或多囊性腎病變的治療?Has a parent or sibling been diagnosed or treated by a health professional for cancer, heart disease, Huntington's Disease or polycystic kidney disease?是否你現在是否使用或要求使用輪椅,助行器,多叉拐杖,醫院病床,透析機,呼吸器氧氣,電動推車或樓梯升降機?Use or require the use of a wheelchair, walker, multi-prong cane, hospital bed, dialysis machine, respirator oxygen, motorized cart or stair lift?是否你現在是否在以下方面需要幫助,協助或監督:洗澡,飲食,穿衣,上廁所,散步,移動或大小便?Need help, assistance or supervision for: bathing, eating, dressing, toileting, walking, transferring, or maintaining continence?是否你現在是否在以下方面需要幫助,協助或監督:服藥,做家務,洗衣服,購物或準備飯菜?Need help, assistance or supervision in: taking medication, doing housework, laundry, shopping or meal preparation?是否您是否曾經被醫學專業人士診斷,治療過,測試呈陽性或曾因以下原因接受過醫學諮詢:跌倒,癱瘓,麻木,震顫,失衡或任何導致運動受限的狀況?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 camotions limited camotion?是否您是否曾經被醫學專業人士診斷,治療過,測試呈陽性或因以下原因接受過醫學諮詢:記憶力減退,精神錯亂,健忘症?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?是否簽字|我已了解以上信息是處於自願提供,僅用於保險代理經紀行或代理經紀人根據此信息,幫助我選擇和比較符合我自身要求的產品。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 my base requireationd. 上一頁 發送我的問卷