McDermott Agency

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McDermott Agency

Insurance Application

Email *

Do you know what kind of policy you are interested in?

Term Policy

Whole Life

IUL

Annuity

Not sure

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Legal Name

Full Address (no PO Box) *

DOB *

YYYY

How old are you today?

Phone Number

Prescription medications & what are the prescribed for? Please LIST the medications you take.

Height

Weight

Have you had any weight changes in excess of 10lbs in the past year? If yes, tell me if you lost or gained and how many lbs and what caused the weigh loss or gain.

Are you a US Citizen?

Yes

Clear selection

Select all that apply

Diabetic requiring insulin

Diabetic 40 yrs or older with A1C >7

Diabetic 40 yrs or less

Charged with felony in the last 10 years

Diagnosed/treated for drug/alcohol abuse in the last 7 years

Heart, liver, pancreas, kidney, or neurological disease in the last 5 years

HIV/AIDS in the last 5 years

TIA/Stroke in the last 5 years

Emphysema or COPD in the last 5 years

DUI/DWI, reckless driving conviction, or license suspended/revoked in the last 5 years

Major depression that required more than 3 medications in the last 5 years

Rheumatoid athritis, lupus, or connective tissue disease in the last 5 years

Awaiting procedure or test results other than pregnancy/fertility/allergies in the last 2 years

Hospitalized in the last year requiring treatment or care

Actively serving in the military

Covid within the last 30 days or under active treatment

None of the listed apply

Have you had cancer of any kind?

Yes

Clear selection

If you answered "YES" to cancer, tell me about it. How many years diagnosed, How many years in remission, ect

Are you a US Citizen?

Yes

Clear selection

Do you have any pending life insurance applications or existing life insurance or annuity contracts with us or any other company?

Yes

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Is this life insurance intended to replace or change an existing life insurance policy?

Yes

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Who is your Employer?

Are you actively serving in the military?

Yes

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What is your occupation?

What are you wanting your policy to do for you? (This can be to pay off debt, mortgage, funeral expenses, sustain family for an amount of time. There is no wrong answer)

Annual income (guesstimate)

Are you currently working?

Yes

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When was the last time you used tobacco?

Never

More than 36 months

12-24 months

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In the last 5 years, have you applied for disability benefits?

Yes

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Have you had a parent or sibling be diagnosed by a licensed medical professional with cerebrovascular disease, cardio-vascular disease, coronary artery disease or stroke or cancer?

Yes - they passed away from this disease

Yes- they did not pass away from this disease

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In the next 2 years do you plan to race motor vehicles, scuba dive, rock or mountain climb, pilot an aircraft or skydive?

Yes

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In the last 2 years, have you engaged in: motor vehicle racing; scuba diving; rock climbing; piloting aircraft (other than for a commercial airline); or skydiving and/or do you intend to do so in the next 2 years?

Yes

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In the last 7 years have you used a narcotic, barbiturate, amphetamine, hallucinogen, heroin, cocaine, or other illegal drug (excluding marijuana), or prescription medication that was not prescribed to you by a licensed medical professional, or has a licensed medical professional recommended that you receive counseling or treatment for alcohol or drug use?

Yes

Clear selection

In the last 10 years has a licensed medical professional diagnosed you with or treated you for cancer (excluding basal cell carcinoma or squamous cell carcinoma of the skin)?

Yes

Clear selection

In the last 2 years has a licensed medical professional advised you to have:

Surgery

Any test or procedure for which you are awaiting results

None of the above

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In the last 7 years have a licensed medical professional diagnosed you for alcohol or drug abuse?

Yes

Clear selection

In the last 10 years have you plead guilty or have charges pending for a felony?

Yes

Clear selection

Within the last year, has a licensed medical professional treated you for Covid or told you to isolate?

Yes

Clear selection

In the last 5 years have you plead guilty or been convicted of DUI/DWI, been convicted of reckless driving or had your license revoked for any reason?

Yes

Clear selection

In the last 3 years, how many speeding tickets or moving violations you have plead guilty to or been convicted of?

Other than conditions already disclosed, have you been hospitalized in the last year for any reason other than childbirth?

Yes

Clear selection

If yes above, are you currently being treated for that condition? Please explain

In the last 5 years has a licensed medical professional diagnosed you with or treated you for any of the following diseases or disorders:

Major depression, bipolar disorder, schizophrenia, suicidal ideation, suicide attempt or other mental health or mood disorder(s) excluding anxiety or stress

Diabetes

Asthma (excluding seasonal allergies), sleep apnea, emphysema, chronic obstructive pulmonary disease (COPD) or any condition requiring the use of oxygen equipment or ventilator

Heart disease, including but not limited to heart attack, heart surgery, coronary artery disease, valve disease, irregular heartbeat, congestive heart failure or cardiomyopathy

Any vascular disease, including cerebrovascular disease, stroke, transient ischemic attack (TIA) or peripheral vascular disease

Chronic kidney disease

Liver cirrhosis, chronic hepatitis or disease of the pancreas

Neurological disease such as amyotrophic lateral sclerosis (ALS), Alzheimer's disease, Parkinson's disease, dementia, Huntington's disease, seizure/epilepsy disorder or cognitive impairment

Degenerative muscle or nerve disease including but not limited to multuple sclerosis (MS), paralysis, or muscular dystrophy

Option 10

Inflammatory Bowel Disease, including ulcerative colitis or Crohn's disease

None of the above

Has a licensed medical professional ever diagnosed you with, provided care or treated you for Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Syndrome (AIDS)?

Yes

Clear selection

Yes

Clear selection

How many alcoholic drinks do you consume per week?

Within the last year have you used marijuana in any form?

Yes

Clear selection

What is your Social Security number? (We use this for identity verification, not a credit inquiry)

Beneficiary legal name and DOB

Complete!

If I have any more questions, I will contact you! You should receive a text soon. Please look over it and approve so that your offer can generate!

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