Applicant Full Name
*
Applicant Date of Birth
Gender
Male
Female
Phone Number
*
Email address
*
Home address
*
Country of birth/city and state
*
Social Security#
*
Drivers' License #
*
Drivers' License State
*
Expiration date of driver's license
*
Current Height
*
Weight
*
Occupation
*
Duties with occupation
*
Annual income
*
$
Have you had any Bankruptcies, levies, liens, foreclosures, repos?
*
No
Yes
Total Amount of other owned life policies.
*
$
Please provide the company name(s), policy number(s), and death benefit amount for each of the other life insurance policies you have in force.
*
Amount of Life insurance applying for with Farmers.
$
Purpose for this Life insurance
Personal- Income Replacement
Personal- Estate Planning / Taxes
Business -Key Man Policy
Business- Buy/Sell
Business- Collateral Assignment
Other
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Will the insured also be the policy owner?
*
Yes
No
Policy Owner Name
What is the policy owner's relationship to the proposed insured?
Who will be paying the premium on this policy?
Desired Payment Plan
Monthly Auto Draft
Annual Premium Paid in Full
Primary Beneficiary Name
*
Primary beneficiary(s) date of birth, address and relationship
Primary Care Physician- Name, Address, Phone #
Reason & date (mm/yy) of last visit to primary care physician?
List of ALL medications you are taking. Please provide the Name, Dosage, Frequency, and reason for each medication.
*
Have you been hospitalized last 2 years for more than 5 days for any reason?
No
Yes
In the last 3 years have you used tobacco/nicotine in any form?
No
Yes
In last 10 years, has your driver's license been suspended, revoked, or have pled guilty or convicted for reckless driving or DUI/DWI?
No
Yes
Are you an active/inactive member of the military?
No
Yes
Have you in the past 2 years or plan to in the next 2 years be a student pilot, member of a flight crew, or participate in hang gliding, para sailing, jumping, rock or mountain climbing, organized racing of autos/motorcycles, boats, snowmobiles, or underwater diving, parachuting, skydiving, ultralight soaring, ballooning, or bungee para kiting?
No
Yes
IN the last 12 months have you lost more than 15 pounds?
No
Yes
Do you have any congenital or birth disorders including blindness, deafness, missing limbs, heart defect, Down's Syndrome, or autism?
No
Yes
In the past 5 years consulted with, been diagnosed or treated by a member of the medical profession or hospitalized or taken medication for any of the following?
High blood pressure
High cholesterol
Chest pain, angina, heart attack, heart murmur, stroke, irregular heartbeat, heart disease or coronary artery
Cancer, tumor, mass, skin cancer, melanoma, leukemia, lymphoma, colon polyp or any malignant or benign growth
Diabetes, impaired glucose tolerance, gestational diabetes, anemia, blood or thyroid disorder or pituitary or adrenal glands
Disorder of liver, pancreas, digestive system, spleen, hepatitis, ulcers, intestinal bleeding, cirrhosis or weight loss surgery
Depression, anxiety, stress, eating disorder, posttraumatic stress, attention deficit, hyperactivity, bipolar or mental health disorder
Seizures, paralysis, multiple sclerosis, memory loss or disease or disorder of the nervous system
Asthma, pulmonary disease, emphysema, chronic bronchitis, sleep apnea or any other disease or disorder of the lungs
Kidney, bladder, urinary, reproductive organ or prostate disorder
Arthritis, fibromyalgia, gout, back or joint pain, muscle disorder or lupus
Treated or diagnosed for HIV or AIDS.
Have you ever used, or been treated for the use of amphetamines, barbiturates, cocaine, marijuana, opiates, hallucinogens or any other illegal drugs or have you been treated by or consulted a member of the medical profession for abuse of prescription drugs?
No
Yes
Have you ever been advised by a medical professional to reduce or stop drinking alcohol or received treatment of any kind for alcohol
No
Yes
Do you currently drink alcohol?
No
Yes
Alcohol- How many drinks per day/week?
In the past 5 years been disabled, received disability income benefits or been unable to work for any other reason besides maternity leave or from minor surgery?
No
Yes
In the past 5 years been diagnosed by a member of medical profession for any other illness, disease, or injury not included in the preceding question or answers
No
Yes
Is your mother still living?
Yes
No
Is your father still living?
Yes
No
How many siblings to you have?
Are all of your siblings still living?
Yes
No