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Americo Eagle Level Pre-Application
Danny Ray
CEO/National Independent Agent
National Producer Number:
16997242
Toll-Free:
(855) 380-3300 Ext 1
Direct:
(888) 531-7955
Fax:
(904) 212-3020
Email:
CEO@InsuranceForBurial.com
Website:
www.InsuranceForBurial.com
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Email
*
Your email
First, we need to gather a little information to begin your application.
1. What is the Insured's Date of Birth?
MM
/
DD
/
YYYY
2. State
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Your answer
Insured Personal Information
1. What is your full name?
*
Your answer
2. Gender?
*
Female
Male
3. Height?
*
Your answer
4. Weight?
*
Your answer
5. Social Security Number?
*
Your answer
6. Place of Birth (State)
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Your answer
7. Will the Insured also be the Policyowner?
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Yes
No
Insured Contact Information
8. Street Address? (street, apt., city, state, zip code)
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Your answer
9. Is Mailing Address different?
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Yes
No
10. How many years has the Insured lived at this address?
*
Your answer
11. If less than 5 years,
What is the Prior Zip Code?
Your answer
12. Please provide an Email Address for the Insured.
*
Your answer
13. Phone Number?
*
Your answer
Product Information
Eagle Premier - Level Day One Coverage
Eagle Guaranteed- Guaranteed Issue
1. What product are you applying for?
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Eagle Premier
Eagle Guaranteed
2. Face Amount? ($5,000 - $40,000)
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Your answer
3. Have you used any nicotine products within the last 12 months?
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Yes
No
4. Should the Automatic Premium Loan feature be added?
This feature pays for premiums from any cash in the policy if the payor misses a premium payment.
*
Yes
No
Riders and Benefits
5. Included Riders and Benefits
Accidental Death Benefit & Accidental Death Benefit Common Carrier
Accelerated Benefit Payment Rider
6. Optional Riders and Benefits (Grandchild Term Rider)
*
Yes
No
Let's get approval to check with some consumer information databases to start the initial underwriting review.
Signer Details
How would you like to sign?
*
Remote Signing - Text Delivery
Remote Signing - Email Delivery
Have you ever been diagnosed, treated, tested positive, or been given medical advice, or prescribed medication by a licensed member of the medical profession for:
1. Alzheimer?s disease, dementia, memory loss, muscular dystrophy, or ALS (Lou Gehrig?s disease)?
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Yes
No
2.
Congestive heart failure, defibrillator placement, cardiomyopathy, chronic kidney disease or kidney failure, or received kidney dialysis?
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Yes
No
3.
Cirrhosis of the liver, Hepatitis (all forms, excluding recovered Hepatitis A), or liver failure?
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Yes
No
4.
Emphysema, chronic obstructive pulmonary disease (COPD), or any other chronic respiratory or lung problem, excluding allergies or asthma?
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Yes
No
5.
Metastatic cancer (cancer that has spread to other parts of the body)?
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Yes
No
6.
Two or more occurrences of cancer of any kind or a reoccurrence of a previous cancer?
*
Yes
No
7.
AIDS, ARC, or HIV?
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Yes
No
In the past 24 months, have you been diagnosed, treated, tested positive, or been given medical advice by a licensed member of the medical profession for:
8.
Internal cancer, brain tumor, or malignant melanoma (excluding basal cell skin cancer)?
*
Yes
No
9.
Complications of diabetes, including amputation, retinopathy (eye disease), nephropathy (kidney disease), neuropathy, insulin shock, or diabetic coma?
*
Yes
No
In the past 12 months, have you been diagnosed, treated, tested positive, been given medical advice or prescribed medication by a licensed member of the medical profession for:
10.
Angioplasty (balloon procedure), stent placement, or heart bypass surgery?
*
Yes
No
11.
Stroke; heart attack, heart valve disease, coronary disease, angina (chest pain), or heart disorder (excluding hypertension)?
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Yes
No
Are you now, or within the past 6 months have you been:
12.
Hospitalized for 48 hours or more, bedridden or confined to or living in a nursing facility or correctional facility?
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Yes
No
13.
Receiving or been advised by a member of the medical profession to receive hospice care?
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Yes
No
14.
Receiving home health care for a chronic or debilitating condition?
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Yes
No
15.
Receiving assistance with activities of daily living, including eating, bathing, toileting, or dressing due to a chronic or debilitating condition?
*
Yes
No
16.
Confined to a wheelchair or using a walker for assistance (except in the case of a temporary condition immediately following injury or medical treatment not to exceed 3 months' time)?
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Yes
No
17.
Using oxygen to assist in breathing?
*
Yes
No
Additional Questions:
18.
In the past 24 months, have you been diagnosed, treated, tested positive, received medical advice, counseling, or been prescribed medication by a licensed member of the medical profession for drug or alcohol abuse/dependency or addiction?
*
Yes
No
19.
Within the last 12 months, have you been advised by a licensed member of the medical profession, to have tests, surgery or hospitalization (except for those related to HIV or AIDS), which have not been completed, or are you waiting for a medical diagnosis or results of medical tests or procedures which have not been received?
*
Yes
No
20.
Have you been diagnosed with a terminal illness that is expected to result in death within 24 months?
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Yes
No
21.
Have you received advice from a licensed member of the medical profession to have, are you waiting for, or have you ever received, an organ or tissue transplant?
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Yes
No
Tell us about any existing insurance already in place.
Is there any existing life insurance or annuity coverage on the life of any Proposed Insured?
*
Yes
No
Existing Policy Details
If Yes, Will this policy be replaced?
Yes
No
Clear selection
If yes, Company Name?
Your answer
If yes, Face Amount?
Your answer
Let us know who should be named as beneficiaries for the primary insured.
Primary Beneficiary Full Name
*
Your answer
Primary Beneficiary Phone Number
*
Your answer
Primary Beneficiary Date Of Birth
*
MM
/
DD
/
YYYY
Primary Beneficiary Relationship to Insured
*
Your answer
Contingent Beneficiary
(optional)
Full Name, Date Of Birth, Phone Number and Relationship To Insured
Your answer
Set up your billing schedule and collect payment information.
Billing information- Monthly Bank Draft
Coverage is not effective until the draft date
OPTIONS:
Today or upon Issue
Pick a Specific Day of the Month
Social Security Billing ( 2nd Wednesday, 3rd Wednesday or 4th Wednesday of the Month)
When would you like to begin your initial draft date?
*
MM
/
DD
/
YYYY
Social Security Billing Option
Second Wednesday
Third Wednesday
Fourth Wednesday
Clear selection
Payor Information
Who will be the payor?
*
Your answer
Bank Account Type?
*
Checking
Savings
Routing Number?
*
Your answer
Account Number?
*
Your answer
Name of your agent:
Danny Ray
Lisamarie Monaco
Clear selection
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