Please fill out the form as completely as possible. We may not be able to provide a quote if the form is not complete.

Applicant Name:

Date of Birth: (e.g. 2/14/1960)       Sex: Male    Female


Height: ft. in.       Weight: lbs.

Partner Name: (if applicable)

Partner Date of Birth: (e.g. 2/14/1960)      

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Leading Edge Options

Benefit Amount: Daily $     Monthly $

Benefit Period: 3 Years    5 Years    5 Years + $1M dollars


Risk Class: Preferred     Select     Class 1     Class 2


Payment Type: Life     10 Pay     Paid-up at 65 (available at age 55)


Riders: Shared Care     Waiver of Elimination Period for Home Care     Nonforfeiture

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1. Have you used tobacco products in the last 12 months?
Yes    No
If yes: type, quantity, number of years used & last used (MM/DD/YEAR):


2. Within the last 5 years, haver you received medical advice, diagnosis, treatment, or consulted with a member of the medical profession for any of the following conditions?

A. Circulatory disorders Yes    No
If yes, list Diagnosis, Diagnosis Date and Treatment dates:


B. Endocrine and pituitary disorders Yes    No
If yes, list Diagnosis, Diagnosis Date and Treatment dates:


C. Cancers Yes    No
If yes, list Diagnosis, Diagnosis Date and Treatment dates:


D. Genital urinary disorders Yes    No
If yes, list Diagnosis, Diagnosis Date and Treatment dates:


E. Gastrointestinal disorders Yes    No
If yes, list Diagnosis, Diagnosis Date and Treatment dates:


F. Neurological disorders Yes    No
If yes, list Diagnosis, Diagnosis Date and Treatment dates:


G. Blood Disorders Yes    No
If yes, list Diagnosis, Diagnosis Date and Treatment dates:


H. Musculoskeletal disorders Yes    No
If yes, list Diagnosis, Diagnosis Date and Treatment dates:


I. Respiratory disorders Yes    No
If yes, list Diagnosis, Diagnosis Date and Treatment dates:


J. Eye and ear disorders Yes    No
If yes, list Diagnosis, Diagnosis Date and Treatment dates:


K. Substance abuse Yes    No
If yes, list Diagnosis, Diagnosis Date and Treatment dates:

3. Do you currently use any assistive or mechanical devices?
Yes    No
If yes, list Diagnosis, Diagnosis Date and Treatment dates:


4. Have you ever received home health care or been confined to a nursing home or rehabilitation facility?
Yes    No
If yes, list Diagnosis, Diagnosis Date and Treatment dates:


5. Do you require human assistance or supervision in performing any of your activities of daily living?
Yes    No
If yes, list Diagnosis, Diagnosis Date and Treatment dates:


6. Have you had a complete physical exam within the past 18 months?
Yes    No


7. List all prescription medication prescribed over teh past 12 months:

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