STANDARD STATES -  SIMPLIFIED ISSUE -  5Star Life with Quality of Life Benefits

  • 5Star Life with Quality of Life Benefits

    Choose $25,000, $50,000 or $100,000 in Term to Age 121 Life Insurance!
  • Today's Date
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  • Gender
  • Date of Birth
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  • Date of Hire
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  • Statement of Insurability

    To the best of your knowledge and belief all answers in this Statement of Insurability are true and correctly recorded, and are made as a consideration for the applied for insurance.
  • In the past 5 years, has any Applicant been diagnosed, treated, or prescribed medication by a medical professional for AIDS, AIDS related complex or an immune system disorder (excluding HIV)?*
  • In the past 6 months, has any Applicant been unable to work or needed personal or mechanical assistance in walking, bathing or dressing or been confined at home, been hospitalized* due to injury or sickness, excluding well-baby delivery and treatment for back pain?*

  • *Hospitalized is defined as an admission for inpatient care in a hospital; receipt of care in a hospice facility, intermediate care facility, or long-term care facility; or receipt of the following treatment wherever performed: chemotherapy, radiation therapy, or dialysis.

  • In the past 12 months has any Applicant had diagnostic testing (excluding HIV test), surgery or hospitalization* recommended by a medical professional which has not been completed or for which the results have not been received?*

  • In the past 5 years, has any Applicant:

  • Been diagnosed, treated, or prescribed medication by a medical professional for any of the following conditions: any disease or disorder of the heart, stroke, cancer, lung disease, chronic respiratory disorder (including any treatment with oxygen but excluding asthma), diabetes requiring insulin, liver or kidney disease?*
  • Been convicted two or more times of driving under the influence of alcohol or drugs or while intoxicated?*
  • Been treated by a medical professional or in a medical facility or received professional counseling for alcohol or drug dependency or been advised to reduce or discontinue use of alcohol?*
  • In the last 10 years, has any Applicant ever applied for and been rejected for life insurance?*

  • DETERMINING YOUR COVERAGE

    Select your age & how much life insurance with living benefits that you're electing in this section
  • Gender
  • Date of Birth
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  • Child #1 Date of Birth
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  • Child #1 Gender
  • Child #2 Date of Birth
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  • Child #2 Gender
  • Child #3 Date of Birth
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  • Child #3 Gender
  • Child #4 Date of Birth
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  • Child #4 Gender
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