Juvenille IUL Life Application

Give your child a strong financial foundation by completing the application below for a Juvenile Indexed Universal Life (IUL) Insurance policy. Having the insured's, policy owner's, beneficiary, and medical information readily available will help you complete the application in approximately 15–20 minutes.

Insured First Name *

Insured Date of Birth *

Insured Gender *

Male

Female

Insured Height in Inches *

Insured Weight (lbs) *

Insured Country of Birth *

Insured State of Birth *

Insured Street Address *

Street Address Line 2

Policy Owner Information

Policy Owner Email *

Policy Owner Phone Number *

Policy Owner Annual Household Income *

Policy Owner Relationship to Primary Proposed Insured *

Policy Owner First Name *

Policy Owner Last Name *

Policy Owner Gender *

Male

Female

Policy Owner Street Address *

Street Address Line 2

Beneficiary Information

Primary Beneficiary First Name *

Primary Beneficiary Last Name *

Primary Beneficiary Street Address *

Street Address Line 2

Percentage of Share * If divided between addt'l beneficiaries, total must equal 100%.

Contingent Beneficiary (Optional) First Name

Contingent Beneficiary (Optional) Last Name

Contingent Beneficiary (Optional) Percentage of Share If divided between addt'l beneficiaries, total must equal 100%.

Contingent Beneficiary (Optional) Street Address

Street Address Line 2

Policy & Coverage Information

Primary Purpose of insurance *

Personal Needs

Business Needs

Is this a Business related sale? *

Yes

Do you currently have any Life Insurance in force or a pending application? *

Yes

YES ONLY, please provide: Company and Face Amount

Will this application reduce or replace current policy? *

Yes

YES ONLY, please provide: Policy Number

Physician Information

Primary Physician: Name, Phone and Address *

Month/Year of Last Visit *

Reason for Dr. Visit *

Temporary Insurance Agreement

Has the Proposed Insured(s) ever been told by a member of the medical profession that he/she had, or consulted a physician for, or received medical treatment for any of the following: disorder of the heart or blood vessels, angina, heart attack, stroke, cancer, tumor, Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or any other immunological disorder, drug dependency, or alcohol dependency? *

Yes

Within the past two years, has the Proposed Insured(s) been hospitalized for more than five days for any reason? *

Yes

Within the past two years, has the Proposed Insured(s) been hospitalized for more than five days for any reason? *

Yes

Within the past 90 days has the Proposed Insured(s) been unable to perform the normal duties of his/her Education for 15 or more school days because of illness or injury? *

Yes

Existing Insurance Information

Is there any life insurance policy or annuity contract in force or application pending on the life of the Proposed Insured, including policies sold or assigned to a trust or viatical/life settlement company? *

Yes

YES ONLY, please list: Insured Name, Company Name, Policy Number

Will any life insurance policy or annuity contract on the Proposed Insured be reduced, replaced, discontinued or payment of premium stopped, if the insurance applied for is issued? *

Yes

YES ONLY, please list: Insured Name, Company Name, Policy Number

Juvenile Plan Information

How many parents or guardians are in the same household? *

Has the insured had for life, accident, or health insurance, or reinstatement of a policy, declined, postponed, cancelled, or issued other than as applied for? *

Yes

YES ONLY, please list: Type of Insurance, Final Action, Reason(s), Date(s)

Do the insured plan to travel or reside outside the US in the next TWO years? *

Yes

YES ONLY, please list: City, Country, Length of Trip, Business or Pleasure

HIV - Application Statement

Notice and Consent for Blood and/or Bodily Fluid Testing

FNWL may request that Insured provide a sample of your blood and/or bodily fluid to test for the presence of Human Immunodeficiency Virus (HIV). The Notice and Consent for HIV Testing form provided with this Application contains information regarding HIV testing, consent, disclosure and notification of test results.

Please designate to whom you wish the results to be released, which may include positive or abnormal HIV, Hepatitis B and/or Hepatitis C results.

I authorize the release of my test results, which may include positive or abnormal HIV, Hepatitis B and/or Hepatitis C results, to my Physician, Health Care Provider or Health Care Agency:

Policy Owner Full Name *

Congenital or Birth Disorders: blindness, deafness, missing limbs, heart defect, Downs Syndrome, Autism? *

Yes

YES ONLY, please enter: Type of Disorder and whether Surgery was necessary

High blood pressure or high cholesterol/hyperlipidemia? *

Yes

YES ONLY, please enter: Type and any Medication

Chest pain, angina, heart attack, heart murmur, stroke or transient ischemic attack/mini stroke (TIA), irregular heart beat/rhythm, other circulatory or heart disorder or coronary artery / heart disease / atherosclerosis? *

Yes

YES ONLY, please list: Type, Medications, Last Follow Up w/Physician

Cancer, tumor, mass, skin cancer including melanoma, leukemia, lymphoma, colon polyp, or any malignant or benign growth? *

Yes

YES ONLY, please enter: Type and Date of Release/Remission

Diabetes, impaired glucose tolerance (pre-diabetes), gestational diabetes, anemia or other blood disorder (excluding HIV), or disease or disorder of the thyroid, pituitary or adrenal glands? *

Yes

YES ONLY, please enter: Type and Medication

Disorder of the liver, pancreas, digestive system or spleen including hepatitis, ulcers, intestinal bleeding, cirrhosis, fatty liver, or weight loss surgery? *

Yes

YES ONLY, please enter: Type and Medication

Depression, anxiety, stress, eating disorder (anorexia or bulimia), post-traumatic stress, attention deficit/attention deficit hyperactivity, bipolar or other psychiatric or mental health disorder? *

Yes

YES ONLY, please enter: Type and Hospitalization in the past THREE years?

Seizures, paralysis, multiple sclerosis, memory loss or other disease or disorder of the nervous system? *

Yes

YES ONLY, please enter: Type and Medication

Asthma, chronic obstructive pulmonary disease, emphysema, chronic bronchitis, sleep apnea or any other disease or disorder of the lungs or respiratory system? *

Yes

YES ONLY, please enter: Type and Medication, Hospitalization in the past FIVE years?

Kidney, bladder, urinary, reproductive organ (other than contraceptive medication) or prostate disorder? *

Yes

YES ONLY, please enter: Type and any Medication or Surgery?

Arthritis, fibromyalgia, gout, back or joint pain or muscle disorder, or Lupus? *

Yes

YES ONLY, please enter: Type and any Medication or Surgery?

In the past five years, has the Insured been diagnosed by a member of the medical profession for any other illness, disease, or injury, not included in your answers to any of the preceding questions? *

Yes

YES ONLY, please enter: Any other illness, disease, or injury, not included in your answers to any of the preceding questions

In the past FIVE years, has the Insured been admitted or advised to be admitted to any hospital or health care facility; or undergone or been advised to have surgery, biopsies, treatment or medical test that are not included in your answers to any of the preceding questions? *

Yes

YES ONLY, please enter: Diagnosis and Date of Release

Status *

Living

Deceased

Unknown

Status *

Living

Deceased

Unknown

Age of Sibling 1 (If No Sibling Put Unknown.) *

Status *

Living

Deceased

Unknown

Age of Sibling 2 (If No Sibling Put Unknown.) *

Status *

Living

Deceased

Unknown

Additional Siblings, please list: Age and Status (living/deceased/unknown)

Any of the above family members suffer from: Alheimer's, Cancer, Heart Disease, Familial Adenomatous, Huntingtons, ALS. *

none of the above

parent 1

parent 2

sibling 1

sibling 2

Which coverage are you interested in? *

How Did You Hear About Us *

How can we help you?

Juvenille IUL Life Application

Juvenile IUL Application

Insured Information

Policy Owner Information

Beneficiary Information

Policy & Coverage Information

Physician Information

Temporary Insurance Agreement

Existing Insurance Information

Juvenile Plan Information

Personal History

HIV - Application Statement

Medical History

Family Health