SIMPLE SUMIT

Legal Name: _________________________________ Gender:_____________ DOB:_________________

Issue State: _______ Product type: _______ Product: _____________ Height:________ Weight:________

INSURED Rate Class: _____________ SMOKER:_____________

Marital status: ________________ SS#: ________________ INSURED CHILDREN

State & Country of Birth: ________________________ Name: ___________________ Gender: _______

Employer: ___________________________________ Birth: ____________________ SS#:___________

Occupation: _________________________________ State & Country of Birth:____________________

Income: ___________________ Net Worth: ____________________ Height & Weight: ______________

Driver’s license or valid ID: _____________________ CURRENT INSURANCE COVERAGE:

Issue State: _______________________ Company Name, coverage amount, replacing? Policy#

Residential Address: _____________________________________________________________

BANK INFORMATION:

Phone: ________________________________ Payor name: _______________________________

Email: ________________________________ Bank Name: _______________________________

BENEFICIARY: PRIMARY

1. Name: ______________________ %Split: _____ Family History: Age (if alive) Age at death Cause of death
Birth: ___________________ SS#: _________________ Mother: _____________, _____________ , _______________
2. Name: ______________________ %Split: _____ Family History: Age (if alive) Age at death Cause of death
Birth: ___________________ SS#: _________________ Mother: _____________, _____________ , _______________

BENEFICIARY: CONTINGENT

1. Name: ______________________ %Split: _____ Family History: Age (if alive) Age at death Cause of death
Birth: ___________________ SS#: _________________ Mother: _____________, _____________ , _______________

Medical Information
Medical Question Medical Condition Medicines Dose Duration

NAME AND ADRESS: __________________________________

DATE LAST SEEN: ____________________________________ REASON: __________________________