Online APPLICATION – Senior Network Care

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SECURE FORM

Insured information:

First name

Middle name

Last name

Gender *

Female Male

Tobacco smoker? *

No Yes

Email *

Phone (MOBILE) *

Home or secondary #

State

City

Zip

Home address

Height (ft)

inches

Weight

Date of birth

Social Security Number

Marital status

Place of birth

US citizenship

US citizen

legal US resident

Employment status *

Employed

Unemployed

Retired

Disabled

Will this insurance replace other policy? *

Yes

Beneficiary information

PRIMARY Beneficiary name

Relationship

DOB - beneficiary

Percent (%)

CONTINGENT Beneficiary name

Relationship

DOB - contingent

Percent (%)

* If you have more beneficiaries, please use the comment box below.

Primary physician information

Physician's name

Physician's phone number

Physician's address

Medical questions - INSURED

Q1. Are you on kidney dialysis, or require oxygen use, or have you received or been advised to get an organ transplant, or been diagnosed with a terminal illness (24 months)? *

No Yes

Q2. Are you currently bedridden, do you require assistance to feed, bathe, dress, or take your own medication or are you currently confined to a hospital, nursing home, assisted living, mental facility, hospice, or require home health nursing care? *

No Yes

Q3. Ever been diagnosed as having or been treated for AIDS, ARC or tested positive for HIV? *

No Yes

Q4. In the last 12 months: other than for temporary or minor conditions, have you been hospitalized two or more times? *

No Yes

Q5. In the last 12 months: other than preventive, maintenance, or risk lowering medications prescribed, have you been treated for or diagnosed with heart attack, stroke, or had heart surgery (including angioplasty)? *

No Yes

Q6. Have you EVER been diagnosed or treated for cancer or brain tumor (other than Basal Cell skin carcinoma)? *

Cancer

Brain tumor

in the last 12 months

in the last 2 years

in the last 4 years

Currently in remission

Still undergoing treatment

Q7. In the last 12 months: Have you used any illegal drugs, been treated for or advised to have treatment for drug abuse? *

No Yes

Q8. Have you EVER: been in a diabetic coma or been advised by a licensed member of the medical profession to have an amputation due to disease or disorder? *

No Yes

Q9. Have you been diagnosed with diabetes (other than gestational diabetes) before the age of 18? *

No Yes

Q10. Have you EVER been diagnosed with, been treated for or advised by a licensed member of the medical profession to receive treatment for Alzheimer’s, dementia, memory loss, organic brain disease, mental incapacity, Lou Gehrig’s disease (ALS), Downs Syndrome, Huntington’s disease, sickle cell anemia, cystic fibrosis, cerebral palsy *

No Yes

Q11. In the past 2 years: Have you been diagnosed or treated for, or are you currently under treatment for: *

Alzheimer’s Disease or Dementia

Heart, Stroke or Circulatory Disorder (except controlled hypertension)

surgery for any Heart Disorder, Angioplasty or Circulatory Disorder (except varicose veins)

Sickle Cell Anemia, Kidney Disease (including dialysis, nephropathy) or Liver Disease (including hepatitis B & C)

Lung Disease (except controlled, mild asthma not requiring any hospitalization in the past 2 years)

ALS (Lou Gehrig’s Disease) or Neurological disorders (including neuropathy, excluding controlled seizure disorder with no seizures in the past 2 years)

Have you been advised by a medical professional to have any tests, surgery, treatment, or further medical evaluation that have not been performed or do you have any medical test results pending

Schizophrenia or Bipolar Disorder

Diabetes requiring insulin treatment

SLE (Systemic Lupus Erythematosus)

Have you excessively used, been treated for, or been advised to have treatment for alcohol or drug abuse

Have you been convicted of operating a vehicle while intoxicated, or had your driver’s license suspended or revoked

Have you been declined or postponed for Life Insurance

NONE OF THE ABOVE

Q12. In the last 10 years: have you been convicted of a felony or currently have pending charges for a felony; or currently on parole from a felony conviction? *

No Yes

Q13. If under age 65, are you currently disabled, or been disabled in the last six months or at any time during the last six months received any disability compensation or been mentally or physically unable to complete 30 hours per week of active employment? *

No Yes not applicable

Q14. Do you now participate in, or do you have plans to participate in any hazardous sport or aviation? *

No Yes

Q15. Are you expecting or planning to have an inpatient surgery in the next 2 years? *

No Yes

List your MEDICATIONS (Rx only), reason, when diagnosed: *

Premium payment information

Is someone OTHER than the insured paying the premium? *

Yes

Financial institution name

Account holder NAME

I agree to pay monthly premiums from my bank account

Routing number

Account number

Day of the month for recurring payments *

Additional info, comments:

Feel free to ask a question or leave a comment. Use this field for additional beneficiaries, list additional health issues, diagnosis, pre-screening questions.

comments

Signature:

Type your FULL NAME (as on your ID) *

Today's date *

Confirm your phone number *

Confirm email address *