Term Life Insurance Application

CEG LIFE

Insurance Services

5 Easy Steps to Getting Insured

Step 1:

Complete the entire application to your right by answering all the questions (if a question does not apply to you, please type N/A), then click on the "Submit" button. This will send your application directly to our office staff in a secure and private manner. A member of our staff will then transfer all of your information to a company-specific application which will be e-mailed to you within 24 hours.

Step 2:

Upon receipt of the company-specific application, please follow the instructions included with the application to sign and return it to us.

Step 3:

After we received your signed application, you will receive a phone call within 48 hours to set up a "mini-physical" at your convenience in your own home.

Step 4:

Within a few weeks after your "mini-physical" you will receive a "Policy Offer" back from the insurance company which we will send to you via e-mail. This you can choose to accept or reject. If you accept it, you will receive your policy in the mail within a week after doing so.

Step 5:

After receiving the policy, sign the "Policy Delivery Receipt" affirming you have received it and send back with your first premium check in a postage-paid envelope. Upon receipt of your first premium check you will be insured!

Life insurance applications on www.ceglife.com are made through CEG LIFE Insurance Services, or through its designated agents, only where licensed and appointed. License numbers are available upon request.

LIFE INSURANCE APPLICATION

Full Name of Applicant:

Date of Birth (MM/DD/YYYY):

Sex:

Street Address:

Apt #:

City:

State:

Zip Code:

Home Phone:

E-mail Address:

Insurance Company:

Term Period:

Marital Status:

Face Amount:

Are you a U.S. Citizen?

If not, do you hold a permanent Visa or Green Card?

Social Security Number:

Driver's License Number:

State of Issue:

Personal Income:

Other Income:

Net Worth:

Do you or your spouse own any other life insurance?

How Much?

Will this replace other coverage?

Current Company:

Year Issued:

Amount:

Any other life insurance applications pending?

Details of any insurance application that was declined, postponed, or modified in any way (if applicable):

Details of disability benefits received for any injury, sickness, or impaired condition (if applicable):

Details of hazardous activities, i.e., airplane pilot, rock climbing, motor vehicle racing, etc. (if applicable):

Details of speeding tickets, license suspension, DWI, or license revocation (if applicable):

Details of planned travel outside the U.S. (if applicable):

Details of belonging to active military/naval organization (if applicable):

Ever filed for bankruptcy?

Date Discharged:

Type:

Details of any felony charges or convictions (if applicable):

Do you now or have you ever used tobacco?

If yes, please provide details (what type, how long, when did you quit, etc.)

Current Medications (if applicable):

Details of any immediate family member's death before the age of 60 (if applicable):

Details of any pending or recommended surgery that has not been completed (if applicable):

Physician Name:

Physician Phone Number:

Physician Address:

Occupation:

Employer:

Employer Phone:

Employer Address:

Beneficiary Name:

Date of Birth:

Relationship:

Type:

Percentage of Benefit:

Beneficiary Name:

Date of Birth:

Relationship:

Type:

Percentage of Benefit:

Beneficiary Name:

Date of Birth:

Relationship:

Type:

Percentage of Benefit:

Beneficiary Name:

Date of Birth:

Relationship:

Type:

Percentage of Benefit:

State of Birth:

Policy #: