Whole Life Insurance & Tax Free Retirement - NexBenefit Insurance Brokerage Service

Address *

Apt, suite, etc.

Country

City

State

Zip code

List all Medications (Separated by Comma) *

Describe all Medical Conditions *

1) Is the Proposed Insured currently disabled or applying for any disability benefits?If Yes, provide details in section L *

Yes

No

2) Used tobacco or nicotine containing products except cigars (e.g. cigarettes, e-cigarettes, pipes, snuff, chewing tobacco or nicotine delivery device such as gum or the patch) *

Last 12 months yes

Last 12 months no

Last 24 months yes

Last 24 months no

3) Used cigars within the last 24 months? *

Yes

No

If Yes, provide number of cigars per year:

4) Used a prescription medication to assist with smoking cessation or as a substitute for smoking (e.g. Chantix, Wellbutrin, etc.) within the last 12 months? *

Yes

No

5) Ever been convicted of a felony, or currently on parole or probation? *

Yes

No

6) Been convicted of operating a motor vehicle while under the influence of alcohol or drugs within the last 5 years? *

Yes

No

7) Been in a motor vehicle accident in which they were found to be at fault, convicted of a moving violation or received a driver’s license restriction or revocation within the last 3 years? *

Yes

No

8) Do you have scheduled plans to travel outside the U.S., or has participated in travel outside the U.S. within the last 2 years? If Yes, use Foreign Travel Supplement *

Yes

No

9) Do you have a written agreement to become, or is currently a member, of the Armed Forces? If Yes, use Military Supplement *

Yes

No

10) Do you currently take classes or is enrolled in a course to become, a pilot, a student pilot or crew member of any aircraft, or has participated in these activities within the last 3 years? If Yes, use Aviation Supplement for Life *

Yes

No

11) Do you take part in diving, hanggliding, parasailing, skydiving, bungee jumping, rock/mountain climbing, skiing, or racing in the last 3 years or have scheduled plans to participate in these activities? If Yes use Avocation Supplement *

Yes

No

Primary Physician/Practice Business Address

Apt, suite, etc.

Country

City

State

Zip code

Employer/business address *

Apt, suite, etc.

Country

City

State

Zip code

16) Net worth *

Policy Amount: Please check the policy amount you would like quotes for. *

1. c) Split Dollar

Assignment

Endorsement

2. a) Is this policy being purchased in connection with an employer-sponsored plan? *

Yes

No

2. b) If Non-qualified, will the policy be issued on a Unisex basis? *

Yes

No

3) Has Proposed Insured(s) and/or Proposed Policy Owner(s) been offered economic incentive like "free" insurance/money to purchase policy or entered into arrangement that entitles lender/investor to portion of death benefit beyond loan repayment? *

Yes

No

4) Does Proposed Insured and/or Policy Owner have a current agreement/commitment to sell, transfer, assign/release this policy or any interest of this policy or its ownership structure to a life settlement company, bank, investor or secondary provider? *

Yes

No

5) Is this policy directly or indirectly owned by a captive insurance company? *

Yes

No

6) Will the source of any premium payments be assets of or from contributions to a captive insurance company? *

Yes

No

Primary Beneficiary Mailing Address *

Apt, suite, etc.

Country

City

State

Zip code

Secondary Beneficiary Mailing Address *

Apt, suite, etc.

Country

City

State

Zip code

Bank Account Type - check only one option in each group below *

Checking

Savings

Individual

Joint

Financial Insitution Address *

Apt, suite, etc.

Country

City

State

Zip code

Accept Terms *

By submitting this request I understand I may receive my quotes via the phone number, email or address provided.

Spam-protection *

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Complete this form to apply for Whole Life Insurance with Tax Free Retirement Income.

Personal Information

Health History

Personal History Information

Coverage Amount

Life Purpose of Insurance

Beneficiary Arrangement

Bank Account Information - Pre-Authorized Check (PAC) Premium Payment Service

You have reached the end of the Whole Life Insurance application.

Complete this form to apply for Whole Life Insurance with Tax Free Retirement Income.

Personal Information

Health History

Personal History Information

Coverage Amount

Life Purpose of Insurance

Beneficiary Arrangement

Bank Account Information - Pre-Authorized Check (PAC) Premium Payment Service

You have reached the end of the Whole Life Insurance application.

Questions? Our support team is ready to help.