PRELIMINARY APPLICATION
FOR
FINAL EXPENSE LIFE INSURANCE

PROPOSED INSURED

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The Proposed Insured is the person to be covered by the insurance policy. The Proposed Insured does NOT have to be the Proposed Owner. If the Proposed Insured is NOT a legal resident of the United States of America, please DO NOT apply as the Proposed Insured will NOT be eligible for coverage.

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PROPOSED OWNER

The Proposed Owner is the person to have authority over the insurance policy. If you, the applicant, DO NOT have a relationship to the Proposed Insured that is "Self", then the Proposed Owner is NOT the Proposed Insured. Therefore, please provide the additional information of the Proposed Owner below. If you, the applicant, DO have a relationship to the Proposed Insured that is "Self", please DO NOT complete the Proposed Owner section of this application as you, the applicant, are the Proposed Owner.

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CONTINGENT DESIGNATED BENEFICIARY

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In the past 12 months, has the Proposed Insured used any form of tobacco or nicotine replacement therapy?
Please confirm if you would like the optional Accidental Death Rider to be included in your insurance policy that would effectively increase the monthly premium? Please note the rider is ONLY eligible with the Level Benefit Plan and the rider CANNOT be added after the insurance policy has been issued.
Does the Proposed Insured have any pending applications or existing life insurance or annuity contracts with the company or any other company?

CURRENT COVERAGE

Is the insurance applied for intended to replace or change any life insurance or annuity contract in force with the company or any other company?
To be Replaced or Converted?
To be Replaced or Converted?

TERMS AND CONDITIONS

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PRIMARY DESIGNATED BENEFICIARY

The Designated Beneficiary is the person to receive the payout of the death benefit after the death of the Proposed Insured. The Primary Beneficiary is the first in line to receive the death benefit. Any named Designated Beneficiary is eligible to receive 100% of the death benefit payout.

UNDERWRITING QUESTIONNAIRE

The Designated Beneficiary is the person to receive the payout of the death benefit after the death of the Proposed Insured. If the Primary Beneficiary dies before the Proposed Insured, the rights to the death benefit will be transferred to the Contingent Beneficiary. If you need to name more than one Contingent Beneficiary, please inform your life insurance agent.

If “Yes” to a question, please provide the below details. If more space is needed, please inform your life insurance agent.

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