TransAmerica

    Thank you for your TransAmerica Term 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.

    Taking 5 minutes to answer these questions may allow the carrier to fast-track your application through underwriting, or at a minimum, save you the hassle of a lengthy telephone interview. Please be sure to answer ALL questions, and give details where required in the "Notes" field of each section.

    We appreciate your quick response. Thank you!


    Personal Information

    Your Full Name (required)

    For Verification, last 4 Numbers of Social Security Number (required)


    Physician's Information

    Have you seen a Physician in the last 5 years? (required)
    YESNO (If "No", skip to next section)

    Physician's Name:

    Physician's Phone Number:

    Physician's City/State/Zip:

    Last Month/Year you saw this Physician?

    What was the reason you saw this Physician?

    What was the Final Result of this visit to this Physician?

    Please add any notes to "YES" answers for Physician's Information below. Also, please include notes below if you have multiple doctors (we'll need to know their Name, Address, Phone, as well as Date, Reason and Result of last visit for each Physician.


    Medical History Information - Section 1

    For Questions 1-14 -- In the past TEN YEARS have you had, been told by a member of the medical profession that you have, or been diagnosed with or treated for... (all questions are required)

    1) Seizure, fainting, stroke, loss of consciousness, tremor, paralysis, multiple sclerosis, epilepsy, or any disease or abnormality of the brain?
    YESNO

    2) High blood pressure, heart attack, murmur, palpitation, or anemia or any disease or abnormality of the heart, blood vessels or blood?
    YESNO

    3) Asthma, chronic bronchitis, pneumonia, emphysema, tuberculosis or any disease or abnormality of the lungs, bronchial tubes or respiratory system?
    YESNO

    4) Ulcer, colitis, hepatitis, cirrhosis, or any disease or abnormality of the esophagus, stomach, intestines, rectum, gallbladder or liver?
    YESNO

    5) Sugar, protein or blood in urine, sexually transmitted disease, stone or any disease or abnormality of the kidney, bladder, prostate, breasts, ovaries or reproductive system?
    YESNO

    6) Diabetes or any disease or abnormality of the thyroid, adrenal, pituitary or other glands?
    YESNO

    7) Arthritis, gout, connective tissue disease, back trouble or any disease or abnormality of the joints, muscles or bones?
    YESNO

    8) Any disease or abnormality of the eyes, ears, nose, throat or skin?
    YESNO

    9) Cancer, tumor, polyp or cyst?
    YESNO

    10) Any physical deformity or amputation?
    YESNO

    11) Anxiety, depression, suicide attempt or any psychiatric, mental or emotional condition or disorder?
    YESNO

    12) At any time in the past, any immune deficiency disorder Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), Human Immunodeficiency Virus (HIV), or tested positive on an AIDS/HIV-related test?
    YESNO

    13) Within the past ten years, have you ever used sedatives, amphetamines, barbiturates, morphine, cocaine/crack, methamphetamine, Ecstacy (MDMA), heroin, marijuana, LSD, PCP, any hallucinogenic drug or narcotic drug except as prescribed by a physician?
    YESNO

    14) Have you ever been treated or counseled or been advised to seek treatment or counseling for the use of alcohol, drugs or other substance or joined an organization for alcohol or drug dependence or abuse?
    YESNO

    Please add any notes to "YES" answers for Section 1 (Questions 1-14) below, and include the Question Number at the beginning of your response.



    Medical History Information - Section 2

    For Questions 15-20, Other than what you have already disclosed, within the past FIVE YEARS have you: (all questions are required). If ANY question below (15-20) is answered YES, please give complete explanation in the section below:

    15) Consulted, been examined or been treated by any physician or practitioner?
    YESNO

    16) Had or been advised to have an X-ray, electrocardiogram, laboratory test or other diagnostic study?
    YESNO

    17) Had observation or treatment at a clinic, hospital or other medical facility?
    YESNO

    18) Had or been advised to have a surgical procedure?
    YESNO

    19) Had dizziness, shortness of breath, pain or pressure in the chest, or persistent fever?
    YESNO

    20) Had an injury requiring treatment?
    YESNO

    Please add any notes to "YES" answers for Section 2 (Questions 15-20) below, and include the Question Number at the beginning of your response.



    Medical History Information - Section 3

    21) Have any of your parents, brothers, sisters or grandparents ever had cancer, diabetes, heart disease, mental illness, or attempted suicide?
    YESNO

    22) Has your weight changed by more than 15 pounds in the past year?
    YESNO

    23) Has any application for life, health, disability or long term care insurance been declined, withdrawn, postponed, rated, modified, issued with exclusion rider, cancelled or non-renewed?
    YESNO

    24) Are you now pregnant?
    YESNO

    25) Other than those already disclosed, are you currently taking any prescription, vitamin, supplement or over-the-counter medication?
    YESNO

    Please add any notes to "YES" answers for Section 3 (Questions 21-25) below, and include the Question Number at the beginning of your response.



    Family History Information

    Does your Father have any history of heart disease, stroke, cancer or melanoma? (required)
    YESNO

    Please indicate condition:

    Age of Diagnosis for any condition above? (If multiple conditions, list condition and Age of Diagnosis.)

    Is your Father deceased? (required)
    YESNO

    If deceased, cause of Death?

    If deceased, age of Death?


    Does your Mother have any history of heart disease, stroke, cancer or melanoma? (required)
    YESNO

    Please indicate condition:

    Age of Diagnosis for any condition above? (If multiple conditions, list condition and Age of Diagnosis.)

    Is your Mother deceased? (required)
    YESNO

    If deceased, cause of Death?

    If deceased, age of Death?


    How many Siblings do you have? (required)

    Ages of Siblings that are currently alive? (required)

    Ages of Siblings that are deceased? (required)

    Do any of your siblings have any history of heart disease, stroke, breast cancer, colon cancer, lung cancer, prostate cancer, ovarian cancer or melanoma? (required)
    YESNO

    Please describe the issue of your siblings, including age diagnosed, diagnosis, and results?

    Please add any notes to "YES" answers for Family History below, and include which Family Member at the beginning of your response.



    Lifestyle Questions

    1) Within the past five years have you used nicotine in any form?
    YESNO

    2) For the last 180 days, have you been actively at work on a full time basis at your usual place of business or employment?
    YESNO

    3) Do you participate in regular weekly exercise?
    YESNO

    4) Do you participate in athletics (Team or Individual)?
    YESNO

    5) Have you ever used any tobacco products?
    YESNO

    6) Do you get regular examinations by your health care provider?
    YESNO

    7) Do you get regular annual dental checkups?
    YESNO

    8) Do you clean your house or do yard work?
    YESNO

    9) Do you have a pet?
    YESNO

    10) Are you a member of a social group or volunteer for charity work?
    YESNO


    Acceptance of Terms of Use

    PLEASE CHECK THIS BOX --> 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. *

    Type your Full Name below, and that will represent your E-Signature. (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!