Life Insurance Application Personal InformationName Last Name DOB City Address State Zip-code Contact Number Email Gender Male Female Other Marital Status Single Married Divorced SSN Nationality Occupation Annual Gross Income Policy InformationType of insurance Term Whole IUL IRAs Annuity Other Payments Frequency Monthly Quarterly Semi-annually Annually Desire Coverage Amount Policy Term Health and LifestyleHeight (fts) Weight (lbs) Do you engage in hazardous activities (e.g., scuba diving, racing)? Yes No Do you participate in any high-risk occupations or hobbies? Yes No Do you smoke or use tobacco products? Yes No Have you used any nicotine products in the last 12 months? Yes No Have you been hospitalized in the last five years? Yes No Do you have any chronic medical conditions? Yes No Have you had any major surgeries in the past? Yes No Have you ever been diagnosed with or received treatment for any of the following:Heart Disease Yes No Diabetes Yes No Cancer Yes No High Blood Pressure Yes No Stroke Yes No Kidney Disease Yes No Liver Disease Yes No Lung Disease Yes No Mental Health Conditions Yes No HIV/AIDS Yes No Other Last Doctor visit date MM slash DD slash YYYY Doctor’s name and location Reason for the visit on this date Current Medications Family History of Major Illnesses (if Applicable)Family history of cancer? Yes No Family history of diabetes? Yes No Family history of stroke? Yes No Beneficiary InformationName Last Name DOB Relationship Percentage allocation Any Existing Life insurance policy Yes No Declaration and Consent: I hereby declare that the information provided above is true and accurate to the best of my knowledge. I understand that any misrepresentation or omission could result in the denial of benefits. I authorize P&T Brokerage and its agents to obtain and disclose information about my health and medical history as required for underwriting and claims processing. Print Name Signature Date MM slash DD slash YYYY
