Pre-application for policies were a simple medical exam or Medical letters are nessessary

Pre-Application for Policies Requiring a Medical Exam or Medical Letters

Complete this form to simplify your application process for policies requiring additional medical documentation. Ensure all details are accurate for faster approval!

Full Legal Name:

Residential Address:

Mailing Address (if different):

Phone Number:

Email Address:

Social Security Number:

Date of Birth:

Citizenship Status:

Government-Issued Photo ID Type and Number:

Bank Account Information (Optional, for policy setup):

Do you have a scheduled medical exam?

Primary Care Physician’s Name and Contact:

Current Medical Conditions:

List of Medications (Name, Dosage, Frequency):

Do you have letters from medical professionals related to your application?

General Family Health History:

Beneficiary Full Name:

Beneficiary Relationship to You:

Beneficiary Date of Birth:

Beneficiary Contact Information:

Disclaimer: This form is intended to assist applicants in providing preliminary information for life insurance policies that may require additional medical documentation, such as medical exams or letters from healthcare professionals.

Important Information About Your Privacy

Voluntary Disclosure: Providing your medical information on this form is completely voluntary. You have the right to withhold medical information without facing any penalties.

Informed Consent: By submitting this form, you acknowledge that you are voluntarily providing medical information for the purpose of evaluating life insurance policy options. The information you provide will be used solely for this purpose and shared only with relevant parties as required.

Data Security: Your medical information will be handled with the utmost care and confidentiality. We implement safeguards to protect your data from unauthorized access, use, or disclosure.

If you have questions about how your information will be used or stored, please contact us at estatechecklist@gmail.com.

estatechecklist@gmail.com. For secure and compliant communication of sensitive documents, we recommend direct submission to your insurance provider.

Pre-application for policies were a simple medical exam or Medical letters are nessessary

Pre-Application for Policies Requiring a Medical Exam or Medical Letters

Important Information About Your Privacy

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