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Agent Resources Inc.
EZ-App
Do Not Use This Process If an Exam is not required or the Owner is other than the Insured.
Agent Contact Info
*
Indicates required field
Agent Name
*
First
Last
Agent Email Address
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Agent Phone Number
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First Name
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Middle
*
Last Name
*
Gender
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Male
Female
Date of Birth
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Social Security
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Drivers License #
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Issue State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
Issue Date
*
Expiration Date
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Home Phone Number
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Work Phone Number
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Mobile Phone Number
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Email
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Contact Preference
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Home Phone
Work Phone
Mobile Phone
Best Time to Call
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Place of Birth
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U.S. Citizen?
*
Yes
No
If "NO" Citizen of Which Country?
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Earned Income
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Unearned Income
*
Net Worth
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Have You Ever used Any Form of Tobacco or Nicotine?
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No
Yes
If Yes: Type and Date Last Used
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Beneficiary Information
Name
*
First
Last
Date of Birth
*
Phone Number
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Address
*
Line 1
Line 2
City
State
Zip Code
Country
SS #
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Percentage
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Type
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Primary
Contingent
Name
*
First
Last
Date of Birth
*
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
SS #
*
Percentage
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Type
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Primary
Contingent
Name
*
First
Last
Date of Birth
*
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
SS #
*
Percentage
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Type
*
Primary
Contingent
Policy Information
Carrier
*
Coverage Amount
*
Plan Type
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1 Year Term
5 Year Term
10 Year Term
15 Year Term
20 Year Term
25 Year Term
30 Year Term
Whole Life
Universal Life
Index Universal Life
Guaranteed UL to Age 80
Guaranteed UL to Age 85
Guaranteed UL to Age 90
Guaranteed UL to Age 95
Guaranteed UL to Age 100
Guaranteed UL to Age 105
Guaranteed UL to Age 110
Guaranteed UL to Age 115
Guaranteed UL to Age 120
Rate Class Quoted
*
Preferred Plus
Preferred Nontobacco
Standard Plus
Standard Nontobacco
Preferred Tobacco
Standard Tobacco
Rated
Table Rating
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None
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Application State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
Planned Modal Premium
*
Premium Payment Mode
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Annual
Semi-Annual
Quarterly
Monthly EFT
Rider 1
*
None
Waiver of Premium
Terminal Illness
Chronic/Critical Illness/LTC
Accidental Death
Child Level Term
Disability Income
Rider 2
*
None
Waiver of Premium
Terminal Illness
Chronic/Critical Illness/LTC
Accidental Death
Child Level Term
Disability Income
Rider 3
*
None
Waiver of Premium
Terminal Illness
Chronic/Critical Illness/LTC
Accidental Death
Child Level Term
Disability Income
Rider 4
*
None
Waiver of Premium
Terminal Illness
Chronic/Critical Illness/LTC
Accidental Death
Child Level Term
Disability Income
Accidental Death Benefit Rider Amount
*
Child Rider Amount
*
Disability Income Rider Amount
*
Existing Insurance
Does the insured have any other insurance inforce ?
*
No
Yes
Will this insurance replace any existing insurance ?
*
No
Yes
If Yes to either answer above please complete the info below:
Ins Co.
*
Policy #
*
Issue Date
*
Death Benefit
*
Replacing?
*
No
Yes
Ins Co.
*
Policy #
*
Issue Date
*
Death Benefit
*
Replacing?
*
No
Yes
Ins Co.
*
Policy #
*
Issue Date
*
Death Benefit
*
Replacing?
*
No
Yes
General Questions
If you answer "Yes" to any questions please provide details in remarks.
Has any person promised or agreed to give or have they given to any party to the application, any inducement, fee or compensation as an incentive to purchase the policy?
*
No
Yes
In the past 5 yrs have you received Workers Compensation, Social Security, or disability payment?
*
No
Yes
Have you ever been convicted of, or are you currently charged with, a felony or misdemeanor, or are you currently on parole or probation?
*
No
Yes
Have you ever sold or transferred any life policy to a third party?
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No
Yes
Do you hold a current pilot license, or have you in the past 5 years flown or do you intend to fly in the next 2 years, other than as a passenger in any type of aircraft?
*
No
Yes
Are you a member or do you intend to become a member of the armed forces, including the reserves?
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No
Yes
Foreign Travel / Hazardous Avocation
Does the proposed insured intend to travel or live outside the U.S. in the next 12 months?
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No
Yes
If "Yes" Provide Reason for Travel, City, Country and Time Frame
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Does the proposed insured participate in any hazardous activities such as hang gliding, hot air balooning, ultra-light flying, heli-skiing, mountain, ice or rock climbing, cliff or base jumping, motor vehicle racing, motorcycle or any other motorized land or water vehicle racing, or scuba or sky diving?
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No
Yes
If Yes, please provide details of any activities
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Include activity, how often, how long participating and any certifications.
Have you Ever Filed for Bankruptcy?
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No
Yes
If "Yes" Provide Discharge Date
*
Any DWI or Other Driving Violations in the Last 5 Years?
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No
Yes
If "Yes" Provide Details
*
provide dates, violations and any court ordered penalization.
Special Requests/Remarks
*
By Clicking the I AGREE check box below, I state the following:
1)
-I am a duly licensed and appointed (if pre-appointment is required) life insurance agent in the State in which the proposed insured was solicited and in the State in which the policy, if one is issued, will be delivered.
2)
-The plan and amount or insurance identified is suitable in view of the owners insurance needs and financial objectives.
3)
-The information provided is complete, accurate and correctly recorded, and
4)
-all required forms have been provided to the applicant.
I Authorize Agent Resources Inc. and/or its fulfillment center representative to obtain such administrative information as may be necessary to complete any life insurance resulting from this lead submission, provided, however that any item of information or question from owner or proposed nsured requiring the act or advice of a licensed life insurance agent will be referred to me for action before the application can be completed.
I will personally review the application created form this data and administrative information provided by the proposed insured and contact him or her concerning any incomplete or inconsistent information and I will not deliver the policy unless I have completed my review and am satisfied that the policy, application and all attached papers, if any are complete and accurate.
All forms required to be delivered at the time of solicitation have been delivered and all other forms (including privacy notice, if necessary) required have been or will be provided to the applicant.
I acknowledge that clicking the "I Agree" and "SUBMIT" Button below constitutes my signature on the form and has the same effect as if I personally signed the form.
I Agree to the statements above.
*
I Agree
Submit
