Home      Contact     Contents     About RPA     Client Success     Financial Planning     Investments     Individual     Corporate   Life Insurance Application I. Proposed Insured First Name Last Name Sex Male Female Height Weight Birth Date Birth Place Street Address City State Zip County Home Phone Work Phone Best time of day to reach Morn. Aft. Eve. Best place to be reached At Home At Work Driver's License Number State Social Security Number Employer Occupation Specific Duties Years Employed Current annual earned income Net Worth Purpose of Insurance II. Other Insurance Does any person to be covered have life insurance or annuities in force? yes no If "yes": Purpose   Name of Company Amount Persona./Bus. Date of issue Person to be Covered a. personal business b. personal business c. personal business Within the past 6 months, has any person to be covered applied for life insurance? yes no If "yes": Who? Company? Amount? Is this policy to replace any existing life insurance or annuity? yes no If "yes": Which policy(s)? a b c III. New Insurance Plan name Face amount Premium quoted Term rider face amount Child rider yes no # Units Child Information   Name(s) of Term Rider Insured, Children Birth Date Birth Place Sex Height 1. Male Female 2. Male Female 3. Male Female 4. Male Female Child Information Continued   Relationship to Proposed Insured Childs SSN Driver's Lic. Number State Weight 1. 2. 3. 4. Premium: Who will pay premiums? Proposed Insured Owner Other If other, please give name and address in Remarks Mode: Annual Semi-annual Monthly Bank Withdrawal IV. Beneficiary Information Provide full name and relationship to Proposed Insured *Primary *Contingent *Primary *Contingent If trust, give date The beneficiary of other persons to be covered will be the owner unless indicated otherwise V. Owner Complete only if other than Proposed Insured First Name Last Name Street Address City State Zip County Relationship to Proposed Insured SSN or Tax ID# If Trust, Give Date VI. Complete the Following Answer the following questions for each person to be covered. For any "yes" answers, please provide complete details. If the information is medical in nature, include: diagnosis treatment and medications: date of occurence, duration and current staus: all names,addresses, and phone numbers of doctors, hospitals and medical facilities consulted. Add to Remarks section below. 1. Is any person to be covered currently or ever been advised to take any medication? yes no 2. Within the past 10 years, has any person to be covered been diagnosed or treated by a member of the medical profession for: high blood pressure; stroke; heart, lung, kidney, or liver disease; diabetes; cancer or tumor; colon disorder; back or spinal disorder; seizure or nervous disorder; alcohol or drug dependency; immune system disorder; digestive, genitourinary problems; mental or depression related problems? yes no 3. Within the past 5 years, has any person to be covered: a. Been hospitalized, examined by, treated by, had any tests or blood studies ordered, or consulted a member of the medical profession? yes no b. Engaged in, or within the next 12 months intend to engage in, skydiving, organized vehicle racing, hang gliding or scuba diving, parachuting or mountain climbing? yes no c. Been hospitalized, examined by, treated by, had any tests or blood studies ordered, or consulted a member of the medical profession? yes no d. Had a driver's license suspended or revoked; had 3 or more moving violations; or been convicted of driving while impaired or intoxicated? yes no 4. Has any person to be covered ever been convicted of, or is awaiting trial for the conviction of a felony? yes no 5. Within the past 3 years, has any person to be covered traveled, or within the next 12 months intend to travel outside the United States? yes no 6. Is each person to be covered a U.S. citizen? yes no If "no": Who? Citizen of: Visa Type: Exp. Date: 7. Has any person to be covered had an application for insurance rated, postponed, or declined?(N/A in Missouri) yes no 8. Has any person to be covered ever been advised to quit or reduce the use of alcohol or been advised to seek treatment or counseling for the use of alcohol or other drugs yes no 9. Has any person to be covered ever used any tobacco or nicotine product? yes no If "yes": Who? What kind? Date last used? How Much? 10. Has any person to be covered ever attempted suicide? yes no 11. Has any person to be covered lost weight in the past year? yes no If "yes": Who? How Much? Reason? 12. Family Record: Living Deceased   Age State of Health Age Cause of Death Father Mother Brother (1) Brother (2) Brother (3) Sister (1) Sister (2) Sister (3) Remarks (Be sure to identify remark with question # and applicable party)

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Retirement Planning Associates is led by James Ellis, a registered representative of,
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