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North Carolina Term Life Insurance Application Questions


Proposed Insured's Information

Name Maiden Name
Sex DOB City & State of Birth

Height Weight

Drivers License Number Drivers License State

Home Address
City, State ZIP
Years at address
Phone Number Best time to Call
email address

Employer Name Years with Employer
Employer Address
Employer City, State ZIP
Employer Phone
Occupation Duties

Owner's Information
Please complete if owner is other than Insured
Owner's Name
Relationship to insured Owner's DOB

Owner's Address
Owner's City, State ZIP

Beneficary Information
Primary Beneficary % Share Relationship to Insured Date of Birth
Contingent Beneficary % Share Relationship to Insured Date of Birth

EXISTING COVERAGE AND PENDING INSURANCE

1. Is the policy applied for intended to replace any existing life insurance or annuity policies with this or any other company?

2. Does anyone proposed for insurance have any other life insurance or annuities in force, or is such person currently applying for any other life insurance besides this application?

If yes, complete below.
Insured's Name Company Face Amount Year Issued Purpose Replacing?

Proposed Insurance Information
Amount of Insurance

Type of Policy

Optional Riders Waiver of Premium Guaranteed Insurability Option

Payor Name - If other than insured

Payor Address

Payor City State Zip

Payment Plan

NonMedical History

This section must be completed if the Proposed Insured is age 18 or over.

1. Has the Proposed Insured:

(a) Applied for or received disability benefits in the last 5 years? YES No
If yes please explain

(b) Applied for life or health insurance that was declined, postponed, or modified, or had reinstatement of an insurance policy denied? YES No
If yes please explain

(c) Flown as a pilot or crew member within the last 2 years, or does the Proposed Insured intend to do so in the future? YES No
If yes please explain

(d) Had more than 2 moving motor vehicle violations in the last 3 years? YES No
If yes please explain

(e) Had his or her driver’s license in a state of revocation, restriction, or suspension or had a driving while intoxicated or driving under the influence of alcohol or drugs violation in the last 5 years? YES No
If yes please explain

(f) Engaged in scuba diving, auto or motorcycle racing, rock or mountain climbing, ultra light flying, hang gliding, or sky diving in the last 2 years, or does the Proposed Insured intend to do so in the future? YES No
If yes please explain

(g) Traveled outside the United States or Canada in the last 2 years, or does the Proposed Insured intend to do so in the next 2 years? YES No
If yes please explain

(h) Been put on alert for or had active duty military service outside the United States or Canada within the last 2 years? YES No
If yes please explain

(i) Been convicted of, charged with, or placed on probation or parole for the commission of any criminal offense in the last 10 years other than a motor vehicle violation? YES No
If yes please explain

(j) Intended for any party other than the owner to obtain any right, title, or interest in any policy issued on the life of the Proposed Insured as a result of this application? YES No
If yes please explain

2. Is the Proposed Insured a US or Canadian citizen or a permanent US resident? YES No
If not, provide country of residence and type of visa
If applicable, provide green card #

3. Please provide details of use of tobacco or any nicotine dispensing products if the Proposed Insured is age 18 or over
Date of last use


Medical History

1. Does the Proposed Insured have a family history (parents) of heart disease, stroke or cancer other than basal cell carcinoma? (If yes, complete details below.) YES No
Proposed
Insured’s
Parents 		Health Condition
(Heart Attack, Stroke, Cancer, etc.) 		Date of Onset Current Age
(If Alive) 		Age at Death
(If Deceased) 		Cause of Death
(If Deceased)
Father   Date:
  Date:
Mother   Date:
  Date:



2. IN THE PAST 5 YEARS has the Proposed Insured:

(a) Used any controlled substance, such as cocaine, heroin, narcotics, amphetamines, barbiturates, sedatives, hallucinogens or marijuana without a medical prescription? YES No
If yes provide Impairment/Condition, Dates, Completely Recovered?, and Doctor or Hospital's Address & Phone Number

(b) Been diagnosed with alcoholism or drug dependence by a member of the medical profession or received treatment, advice, or counseling from any physician, counselor, or other medical provider? YES No
If yes provide Impairment/Condition, Dates, Completely Recovered?, and Doctor or Hospital's Address & Phone Number



3. Has the Proposed Insured EVER had or been told he or she had:

(a) Fainting spells, severe headaches, paralysis, stroke, epilepsy, depression or other mental illness or any disease or disorder of the brain or nervous system? YES No
If yes provide Impairment/Condition, Dates, Completely Recovered?, and Doctor or Hospital's Address & Phone Number

(b) Any breathing disorder including asthma, chronic obstructive pulmonary disease (COPD), sleep apnea, or any disease or disorder of the lungs or respiratory system? YES No
If yes provide Impairment/Condition, Dates, Completely Recovered?, and Doctor or Hospital's Address & Phone Number

(c) Any disease or disorder of the stomach, esophagus, colon, intestines, liver, glands or digestive system? YES No
If yes provide Impairment/Condition, Dates, Completely Recovered?, and Doctor or Hospital's Address & Phone Number

(d) High blood pressure, chest pain, heart attack, heart murmur, anemia, or any disease or disorder of the blood, heart or circulatory system? YES No
If yes provide Impairment/Condition, Dates, Completely Recovered?, and Doctor or Hospital's Address & Phone Number

(e) Diabetes, kidney disease or disorder, or sugar, albumin, or blood in the urine? YES No
If yes provide Impairment/Condition, Dates, Completely Recovered?, and Doctor or Hospital's Address & Phone Number

(f) Arthritis, lupus, or any disease or disorder of the back, bones, joints or muscles? YES No
If yes provide Impairment/Condition, Dates, Completely Recovered?, and Doctor or Hospital's Address & Phone Number

(g) Cancer, leukemia, tumor, or polyp? YES No
If yes provide Impairment/Condition, Dates, Completely Recovered?, and Doctor or Hospital's Address & Phone Number

(h) Any sexually transmitted disease (STD)? YES No
If yes provide Impairment/Condition, Dates, Completely Recovered?, and Doctor or Hospital's Address & Phone Number

(i) Any impairment of hearing or sight, except for the need of corrective lenses? YES No
If yes provide Impairment/Condition, Dates, Completely Recovered?, and Doctor or Hospital's Address & Phone Number

(j) Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Syndrome (AIDS) or tested positive for anti-bodies to the AIDS virus (except by a home testing kit)? YES No
If yes provide Impairment/Condition, Dates, Completely Recovered?, and Doctor or Hospital's Address & Phone Number

(k) A weight loss of 15 pounds or more in the past 12 months (except for pregnancy-related weight loss)? YES No
If yes provide Impairment/Condition, Dates, Completely Recovered?, and Doctor or Hospital's Address & Phone Number



4. Is the Proposed Insured now pregnant? YES No
If yes provide Impairment/Condition, Dates, Completely Recovered?, and Doctor or Hospital's Address & Phone Number

5. Has the Proposed Insured been prescribed or taken any medication in the last 12 months? YES No
If yes provide Impairment/Condition, Dates, Completely Recovered?, and Doctor or Hospital's Address & Phone Number

6. In the past 5 years has the Proposed Insured consulted with or been examined or treated by a medical professional for any reason other than an examination required for employment, school, military service, or marriage? YES No
If yes provide Impairment/Condition, Dates, Completely Recovered?, and Doctor or Hospital's Address & Phone Number

7. In the past 5 years has the Proposed Insured been hospitalized or had an EKG, blood testing or other diagnostic testing or been advised to have a medical test that has not been done? YES No
If yes provide Impairment/Condition, Dates, Completely Recovered?, and Doctor or Hospital's Address & Phone Number

8. Has the Proposed Insured been advised to have or contemplated having a surgical operation that has not been done? YES No
If yes provide Impairment/Condition, Dates, Completely Recovered?, and Doctor or Hospital's Address & Phone Number

9. Has the Proposed Insured had any discussions with any doctor, counselor, or medical provider as to any health and/or medical condition, disorder or diagnosis not previously revealed in answer to questions 2-8 or been personally aware of any such conditions or disorders? YES No
If yes provide Impairment/Condition, Dates, Completely Recovered?, and Doctor or Hospital's Address & Phone Number


Physician’s Name Physician’s Address Physician’s
Phone # 		Date Last
Seen & Reason



Purpose for Insurance

1. Purpose of Insurance If Other please Explain

2. Proposed Insured’s approximate net annual earned income

3. Proposed Insured’s estimated net worth (assets minus debts)

4. In the past 5 years has Proposed Insured filed for bankruptcy or had any liens/judgments filed against him or her? YES No

5. If yes to #4, has bankruptcy been discharged or lien/judgment satisfied?

6. If no to #5, provide details. If yes, provide date discharged or satisfied