Insurance Application – Oros Life Insurance

Insurance Application Form

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Step 1 of 19

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First Name

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Last Name

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E-mail Address

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Phone number

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Date of Birth

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Age

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Coverage Amount

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For How Many Years

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monthly

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yearly

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US Citizen

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Zoho Lead Id

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Gender

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Do you use Tobacco or Nicotine?

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Which Nicotine Products Have You Used In The Past 12 Months?

Enter your Address

Street*

City*

State*

Zip code*

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Full Name

Where were you born?

Enter country or state if born in USA

Do you participate in any of the following activities?

Select all that apply or continue to the next page

Sky Diving

Scuba Diving

Rock Climbing

Private Pilot Privet Pilot

Racing

None of the above

Are you currently employed?*

Yes

This information helps us verify your application

Employer’s name*

Occupation*

What is your annual income?*

Select your gross annual income before taxes

$0–$49,999

$50,000–$99,999

$100,000–$249,999

$250,000 or more

Enter your social security*

Your information is encrypted and secure

Enter your driver's license number*

This helps us verify your identity

State of issue*

In the past 5 years, have you had your driver's license suspended or revoked?*

Yes

In the past 10 years, have you been charged or convicted of a felony or misdemeanor?*

Yes

This information is kept confidential

Has your name changed in the past 5 years*

Yes

Previous Name*

Include maiden names or legal name changes

Height-ft*

Height-in*

What is your weight (lbs)*

Has your weight changed more than 20 lbs in the past year?*

Yes

Significant weight changes may affect rates

Are you currently on any medications?*

Yes

List of medications

List of medications*

Dosage*

Reason*

Add More

Do you have any major health issues?*

Yes

Health Detail*

Do you have any existing life insurance?*

Yes

Will this policy replace any existing life insurance?*

Yes

Replacement policies may require additional documentation

Current Carrier Name*

Policy Number*

Current Face Amount*

Will You Be the Owner of This Policy*

Yes

This owner controls the policy and pays premiums

Owner Name

Relationship to Insured

Your Beneficiary

Full Name

Relationship

Percentage*

Add another beneficiary

Total: 0% (0% remaining)

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Total Percentage

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You're almost finished! Review and sign to complete in under 60 seconds.

Your information is encrypted and secure

Review and Edit your Application

Name

First: {review_first_name}, Last: {review_last_name}

Address

{review_address}

{review_email}

Phone Number

{review_phone_number}

{review_dob_txt}

{review_dob_age}

Gender

{review_gender}

{review_us_citizen} {review_tn}

Personalized Life Insurance Quote

{review_your_quote}

Country or state if born in USA

{review_born_country}

Do you participate in any of the following activities?

{review_participate_activities}

Are you currently employed?

{review_currently_employed}

Annual Income

{review_annual_income}

Social Security

{review_ssn}

Drivers license number

{review_dl}

State of issue

{review_state_of_issue}

In the past 5 years, have you had your drivers license suspended or revoked?

{review_license_suspended}

In the past 10 years, have you been charged or convicted of a felony or misdemeanor?

{review_charged_convicted}

Has your name changed in the past 5 years

{review_name_changed}

What is your height (ft/in) and Weight(lbs)

Height: {review_height} ft {review_inches} in, Weight: {review_weight} lbs

Has your weight changed more than 20 lbs in the past year?

{review_weight_change}

Are you currently on any medications?

{review_medications}

{review_medications_details}

Do you have any major health issues?

{review_health_issue}

{review_existing_insurance}

Will You Be the Owner of This Policy

{review_owner_policy}

Beneficiary

{review_beneficiary}

Authorization and Certification

By signing below, I authorize the insurance company and its agents to obtain information from medical, financial, and investigative sources, including the Medical Information Bureau (MIB), pharmacy benefit managers, motor vehicle records, and other consumer reporting agencies, to evaluate this application. I understand that a brief report of my medical information may be submitted to the MIB. I certify that the statements and answers in this application are true and complete to the best of my knowledge and belief. I understand that any misstatement or omission may result in denial of coverage or rescission of any policy issued.

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Date

MM slash DD slash YYYY

Signature*

Insurance Application Form

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