The Life Insurance Application is a document that may be used by both life insurance
providers and/or applicants. The document contains standard information pertaining to
the determination of eligibility for life insurance benefits or coverage. This is a standard
life insurance application and it may be modified to fit the specific needs of the parties.
It should be used by life insurance providers and individuals applying for life insurance.
LIFE INSURANCE APPLICATION
PERSONAL INFORMATION
Last Name First Name Middle Initial
Street Address City State Zip Zip Code
Home Phone Cell Phone Email Address Email Address
Social Security # Birthdate Driver’s License Number/ State of Issue
Marital Status Gender Height/Weight
❑ Married ❑ Single ❑ Widowed ❑ Divorced ❑ Male ❑ Female
Employer Name Employer Address Years Employed
Tobacco Use? ❑ Yes ❑ No
Major Illness or Medical Condition? ❑ Yes ❑ No
If yes, please explain: _______________________________________________________________________________________________
Hazardous Work Environment? ❑ Yes ❑ No
If yes, please explain: _______________________________________________________________________________________________
MEDICAL HISTORY
Primary Care Clinic Name Primary Doctor Date Last Seen
Street Address City State Zip Zip Code
Phone Number Current Prescriptions Email Address
Reason for Last Doctor’s Visit
Have you ever been diagnosed or treated for the following:
Condition Yes No Condition Yes No Condition Zip Yes No Email Ad
Heart Disease ❑ ❑ Cancer ❑ ❑ Paralysis ❑ ❑
Diabetes ❑ ❑ Allergies ❑ ❑ Muscle Disorder ❑ ❑
Bladder Disorder ❑ ❑ Heart Attack ❑ ❑ Suicide Attempt ❑ ❑
High Blood Pressure ❑ ❑ Depression ❑ ❑ Persistent Headaches/Migraines ❑ ❑
Kidney Disease ❑ ❑ Shortness of Breath ❑ ❑ Pregnancy Complications ❑ ❑
Mental Illness ❑ ❑ Asthma ❑ ❑ Liver Disorder ❑ ❑
Cancer ❑ ❑ Alcoholism ❑ ❑ Arthritis ❑ ❑
Sexually Transmitted Disease ❑ ❑ Irregular Heartbeat ❑ ❑ Other ❑ ❑
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LIFE INSURANCE APPLICATION
BENEFICIARY
Name Social Security Number Relationship Birthdate % Share
Zip
Email Address
OTHER INSURANCE
Insurance Company Policy Number Issue Date Value Beneficiary
GENERAL QUESTIONS
Have you been convicted of a felony or misdemeanor? ❑ Yes ❑ No If yes, explain:
Do you plan to travel or live outside the country in the next 2 years? ❑ Yes ❑ No If yes, explain:
Are you a member or do you plan to become a member of the armed forces? ❑ Yes ❑ No If yes, explain:
Have you ever been denied life or health care insurance? ❑ Yes ❑ No If yes, explain:
Have you ever requested worker’s compensation or social security benefits? ❑ Yes ❑ No If yes, explain:
SIGNATURE
I certify that all statements and information contained in this application are correct to the best of my knowledge and
understand that falsification of this information may result in my ineligibility of benefits or coverage. I authorize any
physician, medical professional, hospital, clinic or organization to provide relevant medical information that may be used
to determine my eligibility for insurance coverage. I release from liability all parties reporting information required by this
application.
I have read, understand, and consent to these statements by my signature below.
Name (Print): __________________________________ Date:____________________
Signature: __________________________________
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LIFE INSURANCE APPLICATION
INFORMATION AND FORMS ARE PROVIDED "AS IS" WITHOUT ANY EXPRESS OR IMPLIED WARRANTY OF ANY KIND
INCLUDING WARRANTIES OF MERCHANTABILITY, NONINFRINGEMENT OF INTELLECTUAL PROPERTY, OR FITNESS
FOR ANY PARTICULAR PURPOSE. IN NO EVENT SHALL DOCSTOC, INC., OR ITS AGENTS, OFFICERS, ATTORNEYS,
ETC., BE LIABLE FOR ANY DAMAGES WHATSOEVER (INCLUDING, WITHOUT LIMITATION, DAMAGES FOR LOSS OF
PROFITS, BUSINESS INTERR