ANICO SI Application

    Thank you for your ANICO Simplified Issue life insurance application. In order to complete the application and forward to the insurance company for an underwriting decision, we need your help in completing ALL of these questions at your earliest opportunity. This form is setup so you can complete everything we need within about 5 minutes.

    Personal Information

    Your Full Name (required)

    9-digit Social Security Number (required)

    Birthplace (State if in US, or Country if outside of the US) (required)

    Approximate Current Height (required)

    Approximate Current Weight in pounds (required)

    Employment Information

    Are you Actively at Work? (required)

    Date of Employment - Month/Year (required)

    Annual Income (required)

    Employer's Name (required)

    Occupation / Job Title (required)

    Business Phone Number (required)

    Health Information

    Have you used Tobacco in the past 12 months? (required)

    Has any Proposed Insured ever been diagnosed or treated with AIDS or AIDS-related conditions? (required)

    In the last 5 years, has any Proposed Insured been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for any of the following (all questions are required). If ANY question below (1-10) is answered YES, please give complete explanation in the section below:

    1) Heart Attack, heart failure, or hospitalized for heart disease?

    2) Diabetes requiring insulin?

    3) Psychiatric impairment requiring hospitalization?

    4) Cerebral vascular accident (stroke) aneurysm, or TIA (transient ischemic attack or "mini-stroke"?

    5) Emphysema or Chronic Obstructive Pulmonary Disease (COPD)?

    6) Kidney Failure, chronic kidney disease, dialysis or organ transplant?

    7) Liver disease, cirrhosis or hepatitis B or C?

    8) Alcoholism or drug abuse history?

    9) Cancer or malignant tumor (excluding basal cell skin cancer), leukemia, or lymphoma?

    10) In the last 6 months, has any Proposed Insured been advised by a member of the medical profession to have any diagnostic testing, treatment, or surgery that has not been completed, except those tests related to the Human Immunodeficiency Virus (AIDS Virus)?

    If any of the answers in Questions 1-10 above are answered yes, please give details to that answer(s) below.

    Policy Owner and Beneficiary Information

    Who will own this policy? (Full Name) (required)

    If the Owner is someone other than the Proposed Insured, please supply their name, gender, relationship to you, Date of Birth and SSN or Tax ID Number below.

    Who will be the Primary Beneficiary on this policy? (Full Name) (required)

    What is the relationship to the Primary Beneficiary? (required)

    What is the Date of Birth of the Primary Beneficiary? (required)

    What is the Gender of the Primary Beneficiary? (required)

    What is the Percentage of the benefit payable to the Primary Beneficiary? (required)

    If there is more than one PRIMARY Beneficiary, please supply their name, gender, relationship to you, Date of Birth and percentage below.

    If you would like to list SECONDARY Beneficiary(s), please supply their name, gender, relationship to you, Date of Birth and percentage below for EACH entity or person. (Percentages must add up to 100%.)

    Existing Insurance Information

    Do you have any existing life insurance or annuity coverage?

    Is the insurance applied for intended to replace, in whole or in part, any existing insurance or annuity?

    Only if you answered "YES" above, please supply the name of the company that you are replacing.

    Only if you answered "YES" above, please supply the amount of the coverage that you are replacing.

    Acceptance of Terms of Use

    By checking this box, you agree that as the Proposed Insured, you believe each of these answers and details to be true and complete to the best of your knowledge and belief. You also understand that any misrepresentation contained in this submission and relied on by the company may be used to reduce or deny a claim or void the policy if: (1) such misrepresentation materially affects the acceptance of risk, and/or (2) the policy is within its contestable period. Finally, you agree to hold harmless all parties associated with this application for life insurance, including but not limited to the agent, brokerage operation, application processing center, and carrier. *

    Your Email (required)

    We appreciate your business, and look forward to assisting you in completing this life application and getting coverage inforce as soon as possible.

    Thank you for your time and attention!