Welcome to Beneftis Mutual Insurance

Life Insurance Form

GENERAL INFO

Applicant

Spouse/Co-applicant

NAME:

PHONE:

ADDRESS:

DATE OF BIRTH:

GENDER:

Male Female

SMOKING HISTORY:

HEIGHT:

FEET INCHES

WEIGHT:

E-MAIL:

DESIRED COVERAGE

TYPE OF COVERAGE:

AMOUNT OF COVERAGE:

COVERAGE WILL BE:

QUALIFYING QUESTONS:

We have many carriers who specialize in high risk policies. Please answer the following questions as accurately as possible.

QUESTION 1:

DO YOU PARTICIPATE IN RACING, SKY DIVING, HANG GLIDING, MOUNTAIN CLIMBING OR ANY OTHER HAZARDOUS ACTIVITY OR OCCUPATION?:

YES NO

DOES THE CO-APPLICANT PARTICIPATE IN RACING, SKY DIVING, HANG GLIDING, MOUNTAIN CLIMBING OR ANY OTHER HAZARDOUS ACTIVITY OR OCCUPATION?:

YES NO

QUESTION 2:

HAVE YOU BEEN UNDER THE TREATMENT OF A DOCTOR WITHIN THE PAST 3 YEARS FOR A HEART ATTACK, STROKE, CANCER, DIABETES, BYPASS SURGERY, EMPHYSEMA, KIDNEY, CORONARY ARTERY OR LIVER DISEASE, CHRONIC BRONCHITIS OR CHRONIC ASTHMA?:

YES NO

HAS THE CO-APLICANT BEEN UNDER THE TREATMENT OF A DOCTOR WITHIN THE PAST 3 YEARS FOR A HEART ATTACK, STROKE, CANCER, DIABETES, BYPASS SURGERY, EMPHYSEMA, KIDNEY, CORONARY ARTERY OR LIVER DISEASE, CHRONIC BRONCHITIS OR CHRONIC ASTHMA?:

YES NO

PLEASE SEND ME MONEY SAVING OFFERS ON AUTO INSURANCE

AUTO POLICY EXPIRATION DATE (if box checked above):

CURRENT AUTO INSURANCE CARRIER:

By submitting this form you agree that the above information is complete and correct. Additionally, some states may require your expressed written consent for your medical information to be released to others. By providing any medical information to us you are explicitly waiving your right to privacy and granting us your permission to share this information with others for the purpose of providing insurance quotations.