Paper App

eApp Questions

Anything you filled in on the Master Script shows up here automatically. Work top to bottom while you're on the call, then hit Save as PDF and print to PDF.

0 of 65 fields answered

Applicant

Read it back to them as you type. Spell the name out loud.

Full name

Date of birth

Height / Weight

Sex

TU or NTU

State born in

Beneficiaries and relationship

Driver's license # and state

Social Security number

US citizen

Address

Phone number

Employment and employer name

Coverage amount and price (HP Pro)

Doctor

Doctor name

Facility

Address

Phone

Last seen

Prescription medications

Banking

Confirm routing and account digit by digit before you move on.

Bank name, city, state

Routing number

Account number

Draft date

Senior (60+) health questions

Everything else is NO. Ask them cleanly, do not lead.

Has the proposed insured ever been rejected for life insurance by American Income Life?

Has the proposed insured used tobacco in the past 12 months?

Been advised that they have a terminal illness?

Been advised that they have or have had heart attack, lung, liver or bone marrow transplant?

Been diagnosed or treated for cirrhosis, Alzheimer's, ALS or senile dementia?

Been diagnosed as having or received treatment for chronic kidney failure, including kidney dialysis?

Been diagnosed or treated for AIDS or had test results indicating exposure to HIV?

Had a toe, foot or leg amputated due to illness or disease?

In the past 2 years, been hospitalized for heart attack, stroke, or diagnosed/treated for cancer (other than non-melanoma skin cancer) or other malignant tumor or growth?

Is the proposed insured bedridden, hospitalized, a resident of a nursing facility, or require oxygen equipment in the home setting?

Super Combo (59 and under)

In the last 20 years, treated or advised for alcoholism, alcohol abuse, AA, or advised to reduce alcohol consumption?

Cocaine, amphetamines, barbiturates, hallucinogens, tranquilizers, narcotics, or anything illegal not prescribed by a professional?

Driver's license suspended or revoked due to a violation or arrest (including DUI or DWI)?

Flown as a pilot in the last 2 years or plan to as a pilot or crew member?

Last 2 years: any auto, motorcycle or boat racing, parachute jumping, skin diving, scuba diving, sky diving?

Advised in the last 10 years of anything relating to high blood pressure, chest pain, heart attack, stroke, or any heart, blood or circulatory disorder?

Treated for diabetes or other endocrine disorder?

Treated for paralysis, epilepsy, mental disease or disorder, or any other nervous system or brain disorder?

Last 10 years: arthritis?

Last 10 years: injury to or trouble with your back, knees or any joints?

Last 10 years: advised to take tests, results not yet received, or diagnosed/treated for cancer?

Last 10 years: tumors?

Last 10 years: unexplained masses?

Rejected for life or medical-hospital insurance, rated, or failed to receive a policy as applied for?

Last 5 years: physical exam?

Last 5 years: medical treatment (including prescription medication)?

Last 5 years: hospitalizations?

Resident of a nursing home, or diagnosed as having a terminal illness or Alzheimer's?

Ever treated for asthma, emphysema, sleep apnea or other respiratory disorder?

Ever treated for ulcer, colitis or other digestive tract disorder?

Ever treated for cirrhosis, hepatitis or other liver disorder, any blood disorder, or received a bone marrow transplant?

Ever treated for kidney, prostate, urinary bladder or other genitourinary disorder?

Ever treated for disease of the breasts, uterus or ovaries?

Ever treated for rheumatoid arthritis or any other musculoskeletal disorder?

Loss of hearing or loss of sight?

AIDS, AIDS related complex (ARC) or AIDS related conditions?

Ever tested positive for antibodies to the 'AIDS' (HIV) virus?

Smoke cigarettes or use tobacco in any form?

If former tobacco user — date they quit

Any marijuana in the past year?

eApp — Paper Application

Wilkit Primary — internal use only.

Applicant

Full name
Date of birth
Height / Weight
Sex
TU or NTU
State born in
Beneficiaries and relationship
Driver's license # and state
Social Security number
US citizen
Address
Email
Phone number
Employment and employer name
Coverage amount and price (HP Pro)

Doctor

Doctor name
Facility
Address
Phone
Last seen
Prescription medications

Banking

Bank name, city, state
Routing number
Account number
Draft date

Senior (60+) health questions

Has the proposed insured ever been rejected for life insurance by American Income Life?
Has the proposed insured used tobacco in the past 12 months?
Been advised that they have a terminal illness?
Been advised that they have or have had heart attack, lung, liver or bone marrow transplant?
Been diagnosed or treated for cirrhosis, Alzheimer's, ALS or senile dementia?
Been diagnosed as having or received treatment for chronic kidney failure, including kidney dialysis?
Been diagnosed or treated for AIDS or had test results indicating exposure to HIV?
Had a toe, foot or leg amputated due to illness or disease?
In the past 2 years, been hospitalized for heart attack, stroke, or diagnosed/treated for cancer (other than non-melanoma skin cancer) or other malignant tumor or growth?
Is the proposed insured bedridden, hospitalized, a resident of a nursing facility, or require oxygen equipment in the home setting?

Super Combo (59 and under)

In the last 20 years, treated or advised for alcoholism, alcohol abuse, AA, or advised to reduce alcohol consumption?
Cocaine, amphetamines, barbiturates, hallucinogens, tranquilizers, narcotics, or anything illegal not prescribed by a professional?
Driver's license suspended or revoked due to a violation or arrest (including DUI or DWI)?
Flown as a pilot in the last 2 years or plan to as a pilot or crew member?
Last 2 years: any auto, motorcycle or boat racing, parachute jumping, skin diving, scuba diving, sky diving?
Advised in the last 10 years of anything relating to high blood pressure, chest pain, heart attack, stroke, or any heart, blood or circulatory disorder?
Treated for diabetes or other endocrine disorder?
Treated for paralysis, epilepsy, mental disease or disorder, or any other nervous system or brain disorder?
Last 10 years: arthritis?
Last 10 years: injury to or trouble with your back, knees or any joints?
Last 10 years: advised to take tests, results not yet received, or diagnosed/treated for cancer?
Last 10 years: tumors?
Last 10 years: unexplained masses?
Rejected for life or medical-hospital insurance, rated, or failed to receive a policy as applied for?
Last 5 years: physical exam?
Last 5 years: medical treatment (including prescription medication)?
Last 5 years: hospitalizations?
Resident of a nursing home, or diagnosed as having a terminal illness or Alzheimer's?
Ever treated for asthma, emphysema, sleep apnea or other respiratory disorder?
Ever treated for ulcer, colitis or other digestive tract disorder?
Ever treated for cirrhosis, hepatitis or other liver disorder, any blood disorder, or received a bone marrow transplant?
Ever treated for kidney, prostate, urinary bladder or other genitourinary disorder?
Ever treated for disease of the breasts, uterus or ovaries?
Ever treated for rheumatoid arthritis or any other musculoskeletal disorder?
Loss of hearing or loss of sight?
AIDS, AIDS related complex (ARC) or AIDS related conditions?
Ever tested positive for antibodies to the 'AIDS' (HIV) virus?
Smoke cigarettes or use tobacco in any form?
If former tobacco user — date they quit
Any marijuana in the past year?