Senior Care Plus

Life Insurance

At Associated Insurance Professionals we greatly appreciate your interest in our term life insurance programs and look forward to working with you. Please be aware that this is not an application. This is a request for an application. You are under no obligation by completing this form and no company will receive any of your personal data or information until you receive, review and sign the specific company application you requested. If you have not received a pricing proposal yet, please visit either our "Instant Quote" sections of our website, or call us toll free at (800) 734-6078.

Once you have completed the request form we will transfer your specific detail to the selected company application and return it for your review and signature. Please visit our "Understanding the Application Process" page on this website for more specific details.

Once again, we greatly appreciate your business and look forward to being of further service. When you have completed this form, please click the "Send Information" button appearing at the bottom of this form.

Applicant Information

MM/DD/YYYY
City, State and County if applicable


Ex. 123-45-6789
123456789

Residence




Contact user@company.com

include dashes
include dashes

Employer




Income


Terms of Policy Requested

Ex: 20 years

1 unit is $1,000


If you choose the Monthly Option, your monthly premium will be debited automatically from the checking account you specify.
Health Information for Proposed Insured

Please answer the following questions carefully. This information is very important in helping us get your policy issued as soon as possible.


Ex: # Cigarettes, 20 per day, Yesterday




Beneficiary Information

Please enter full name, percentage share, and relationship for proposed unsured for the beneficiaries of this policy.

Example: Mr. John A. Jones, 50 percent, Father
Examples: Mrs. Elizabeth P. Jones, 50 percent, Mother
Total Life Insurance Currently in Force

If yes, please provide the following information about your Life Insurance

Ex: Aetna, $150,000, 1992

If yes, please provide the following information about the policies/annuities that will be affected.

Ex: Aetna, $150,000, 1992
General Information

Please answer the following questions carefully. This information is very important in helping us get your policy issued as soon as possible.

The following questions apply to the proposed insured. Please give full details to any "YES" questions in the COMMENTS area at the bottom of this section.







Health Statement

The following questions apply to the proposed insured. Please give full details in the comments area appearing at the bottom of this section.


If yes, identify family member, disorder, age at death in comments section.



Ex: I am taking ProCardia 200 mg/day. I have diabetes