Life Insurance Application | Legacy Financial Security

This application is for individuals who have received an online life insurance quote and wish to proceed toward underwriting approval. All information is confidential, securely transmitted, and stored using encryption. Submission does not guarantee approval or issuance of a policy. Coverage, rates, and final approval are determined by the insurance carrier following underwriting review.

Applicant Information (Proposed Insured)

The person to be covered under the insurance policy.

First Name *

First name is required

Middle Name

Last Name *

Last name is required

Date of Birth *

Date of birth is required

Social Security Number *

Valid SSN required (XXX-XX-XXXX)

Gender *

Gender is required

Marital Status *

Marital status is required

U.S. Citizen *

This field is required

Birthplace — City, State

Birth Country

Residence Address

Street Address *

Street address is required

Street Address Line 2

City *

City is required

State *

State is required

Zip Code *

Zip code is required

How long have you lived at this address?

Phone Number *

Valid phone number is required

Email Address *

Valid email address is required

Driver's License or State ID Number

Driver's License State

Driver's License Expiration Date

Employment & Financial Information

Employment Status *

Employment status is required

Name of Employer

Occupation / Job Title

Type of Business

Duration of Employment

Employer Address

Street Address

City

State

Zip Code

Annual Income *

Annual income is required

Household Annual Income

Net Worth

Have you filed for bankruptcy in the past 10 years? *

This field is required

Coverage Details & Existing Insurance

Coverage Amount You Are Applying For *

Coverage amount is required

Product Type

Insurance Carrier

Quoted Monthly Premium

Existing Insurance

Do you currently have any life insurance or annuity policies in force? *

This field is required

Existing Policy Carrier Name

Existing Policy Number

Existing Coverage Amount

Existing Policy Type

Is this application intended to replace or change any existing life insurance or annuity policy? *

This field is required

Do you have any life insurance applications pending with any other company? *

This field is required

Have you ever been declined, rated, or had a life insurance application postponed or modified by any company? *

This field is required

If yes, provide details

Health Screening

Height *

Height is required

Weight *

Weight is required

Have you used tobacco or nicotine products in the past 12 months? *

This field is required

Medical History

Have you been diagnosed with or treated for any of the following conditions in the past 10 years? *

Heart disease, heart attack, or stroke

Cancer or tumors

Diabetes

Kidney or liver disease

Mental health condition (depression, anxiety, bipolar, etc.)

Respiratory disease (COPD, emphysema, asthma, etc.)

Neurological condition (epilepsy, multiple sclerosis, etc.)

None of the above

Please select at least one option

If you selected any conditions above, please provide details

Are you currently taking any prescription medications? *

This field is required

List your current medications:

Medication 1 Name

Dosage

Condition/Reason

Medication 2 Name

Dosage

Condition/Reason

Medication 3 Name

Dosage

Condition/Reason

Medication 4 Name

Dosage

Condition/Reason

Medication 5 Name

Dosage

Condition/Reason

Have you been hospitalized or had any surgeries in the past 10 years? *

This field is required

If yes, please describe

Are you currently receiving or have you applied for disability benefits? *

This field is required

Have you ever been advised to have, or are you awaiting, any medical test, surgery, or treatment? *

This field is required

If yes, please describe

Have you been treated for or diagnosed with alcohol or substance abuse? *

This field is required

Primary Care Physician & Family History

Primary Care Physician or Medical Facility

Physician or Facility Name

Street Address

City

State

Zip Code

Physician/Facility Phone Number

Date Last Seen

Reason for Last Visit

Family Medical History

Information about your immediate biological family members.

Is your biological father still living?

Father's current age or age at death

If deceased, cause of death

Is your biological mother still living?

Mother's current age or age at death

If deceased, cause of death

Number of siblings

Ages of siblings if living

Have any parents or siblings been diagnosed with heart disease, cancer, diabetes, or stroke before age 60?

If yes, please describe

Lifestyle & Risk Factors

Have you had a DUI or DWI conviction in the past 5 years? *

This field is required

Have you ever been convicted of a felony or are you currently on probation or parole? *

This field is required

If yes, please describe

Do you participate in any of the following activities? *

Private aviation (non-commercial pilot)

Skydiving or base jumping

Rock or mountain climbing

Motorsports or racing

Scuba diving (below 100 ft)

None of the above

Please select at least one option

Do you fly or intend to fly as anything other than a fare-paying passenger on a scheduled commercial airline? *

This field is required

If yes, please describe

Are you currently an active member of the military, military reserves, or National Guard? *

This field is required

Branch of Service

Rank

Are you currently deployed or scheduled for deployment?

Have you traveled outside the United States or Canada in the past 2 years, or do you plan to within the next 2 years? *

This field is required

If yes, provide details

Beneficiary Information

The beneficiary receives the death benefit from your insurance policy.

Primary Beneficiary

Beneficiary Type *

Beneficiary type is required

First Name *

First name is required

Middle Name

Last Name *

Last name is required

Date of Birth *

Date of birth is required

Social Security Number *

Valid SSN required (XXX-XX-XXXX)

Relationship to Applicant *

Relationship is required

Phone Number

Email Address

Street Address

City

State

Zip Code

Percentage of Death Benefit *

Percentage is required

Contingent (Secondary) Beneficiary — Optional

Receives the death benefit only if the primary beneficiary is unable to.

Contingent Beneficiary Type

First Name

Middle Name

Last Name

Date of Birth

Social Security Number

Relationship to Applicant

Phone Number

Email Address

Street Address

City

State

Zip Code

Percentage of Death Benefit

Policy Owner & Premium Payor

Policy Ownership

The policy owner has ownership rights over the insurance policy. In most cases, the policy owner is the same person being insured.

Is the policy owner the same as the applicant (proposed insured)? *

This field is required

Owner First Name

Owner Middle Name

Owner Last Name

Owner Date of Birth

Owner Social Security Number

Owner Gender

Owner Relationship to Applicant

Owner Phone Number

Owner Email

Owner Street Address

City

State

Zip Code

Owner Driver's License No. / State

Owner Occupation

Owner Annual Income

Premium Payor

The person responsible for paying the insurance premiums.

Who will be paying the premiums? *

This field is required

Payor First Name

Payor Middle Name

Payor Last Name

Payor Relationship to Applicant

Payor Date of Birth

Payor Social Security Number

Payor Phone Number

Payor Email

Payor Street Address

City

State

Zip Code

Payment Information

Premium payments will be drafted from the bank account provided below.

Preferred Payment Frequency *

Payment frequency is required

Preferred Monthly Draft Date *

Draft date is required

Bank Name *

Bank name is required

Account Type *

Account type is required

Routing Number *

Routing number is required

Account Number *

Account number is required

Name on Account *

Account holder name is required

Is the account holder address the same as the applicant's address?

Account Holder Address

Street Address

City

State

Zip Code

Review & Submit

Please review all the information you have provided in this application. By checking the box below and submitting, you confirm that all statements are accurate. This is not a binding insurance contract — it is an internal application used by Legacy Financial Security to gather the information needed to process your life insurance request with the appropriate carrier.

You must certify that the information provided is accurate

Today's Date

Application Received

Thank you for submitting your life insurance application with Legacy Financial Security. Your application is now under review.

A licensed agent will contact you if any additional information is needed.

For questions, call (916) 602-4428 or email info@legacyfinancialsecurity.com