Private Life Insurance Application | Apex Insurance Solutions

1

Applicant Information

Full Legal Name *

Date of Birth *

Gender *

State of Residency *

Social Security Number (HIPAA Authorization) *

Required for HIPAA authorization and carrier underwriting. Your information is encrypted and secure.

Physical Measurements

Height (ft) *

Height (in) *

Weight (lbs) *

Contact Information

Home Street Address (Physical — No P.O. Box) *

City *

State *

ZIP Code *

Primary Phone *

Secondary Phone

Email Address *

Identity & Citizenship

Are You a U.S. Citizen? *

Yes No

Country of Birth *

State of Birth *

Do You Have a Driver's License? *

Yes No

Driver's License Number

Driver's License State

2

Coverage & Policy Information

Will the Proposed Insured Be the Policy Owner? *

Yes No

In the Past 13 Months, Has the Proposed Insured Used Tobacco or Any Nicotine Product? *

Yes No

Existing Life Insurance & Annuity Policies

List all active life insurance policies and/or annuity contracts on any person proposed for insurance that are now pending or now in force (including any that have been assigned or sold). If none, enter N/A.

Existing Policies / Annuity Contracts *

Policy Replacement Questions

Has the Proposed Insured had, or do they intend to have, any life insurance policies or annuity contracts replaced, converted, reduced, reissued, sold, subjected to borrowing, or otherwise discontinued because of this application? *

Yes No

Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract? *

Yes No

Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract? *

Yes No

Are you planning to enter into a finance arrangement to pay any premium payments due under this policy? *

Yes No

Do you intend to sell or transfer ownership to a third party in the next five years, or have you sold or transferred ownership of a policy to a third party in the last five years? *

Yes No

In the past 10 years, has the Proposed Insured been declined for life insurance coverage? *

Yes No

Has the Proposed Insured been offered cash or any other consideration for obtaining this policy? *

Yes No

3

Risk Assessment — Occupation & Lifestyle

Is the Insured Currently Employed? *

Yes No

Employer *

Annual Income *

Enter numbers only — no $, commas, or special characters.

Occupation Field (Select All That Apply)

Lifestyle & Activities

In the next 2 years, will the Proposed Insured engage in any motor sports racing, boat racing, parachuting/skydiving, hang gliding, base jumping, rock or mountain climbing? *

Yes No

4

Medical History

Answer all questions as they apply to the Proposed Insured. All questions are required.

Has the Proposed Insured ever been diagnosed with, received treatment for, or been advised by a member of the medical profession to seek treatment for:

Cardiovascular: Coronary Artery Disease, Heart Attack, Coronary Artery Bypass Surgery, Angioplasty, Stent Placement, Valvular Heart Disease with Repair or Replacement, Cardiomyopathy, Congestive Heart Failure, Congenital Heart Disease, Pacemaker, Defibrillator, Stroke, Transient Ischemic Attack (TIA) / mini-stroke, abnormal heart rhythm, or Cerebral, Aortic or Thoracic Aneurysm? *

Yes No

Chronic Lung Disease (except mild Asthma), including Chronic Obstructive Pulmonary Disease (COPD), Chronic Bronchitis, Emphysema, Sarcoidosis or Cystic Fibrosis? *

Yes No

Neurological / Mental Health: Bipolar Depression, Schizophrenia, Alzheimer's Disease, Dementia, Parkinson's Disease, Sickle Cell Anemia, Lou Gehrig's Disease (ALS), Muscular Dystrophy, Demyelinating Disease including Multiple Sclerosis, Huntington's Disease, Hydrocephalus, Quadriplegia, Paraplegia, Down Syndrome, Autism, Intellectual Developmental Disorder, or any other disease of the central nervous system? *

Yes No

Kidney / Liver / Pancreas: Chronic Kidney Disease, end-stage Renal Disease with dialysis, Chronic Pancreatitis or Liver Disease including Cirrhosis, Hepatitis B or Hepatitis C? *

Yes No

Cancer: Cancer, Leukemia, Melanoma, Lymphoma or any other internal cancer (except basal cell or squamous cell skin cancer)? *

Yes No

Autoimmune: Systemic Lupus or Scleroderma? *

Yes No

Organ Transplant: An organ transplant? *

Yes No

HIV/AIDS: Has the Proposed Insured ever been diagnosed by a member of the medical profession or been tested positive for Human Immunodeficiency Virus (AIDS virus) or Acquired Immune Deficiency Syndrome (AIDS)? *

Yes No

Has the Proposed Insured currently or within the past 12 months:

Required the assistance of another person or a device of any kind for bathing, dressing, eating, toileting, getting in and out of a chair or bed, or the management of bowel or bladder problems? *

Yes No

Received, or been advised by a member of the medical profession to have, any of the following types of care: nursing home, assisted living facility, adult day care facility, home health care services, hospice care or is the Proposed Insured currently confined to any hospital or other medical facility? *

Yes No

Used any of the following: walker, wheelchair, electric scooter, oxygen (excluding use for sleep apnea), or catheter? *

Yes No

In the past 12 months, has the Proposed Insured been advised by a member of the medical profession to have a surgical operation, diagnostic testing (other than for routine screening purposes or for those related to HIV/AIDS), treatment, or other procedure which has not been done? *

Yes No

In the past 12 months, has the Proposed Insured received treatment by a member of the medical profession for chronic cough, unexplained weight loss greater than 10 pounds (other than due to diet or exercise), fatigue or unexplained gastrointestinal bleeding? *

Yes No

Has the Proposed Insured ever been diagnosed with, received treatment for, or been advised to seek treatment for:

Diabetes? *

Yes No

Diabetes before age 45 other than Gestational Diabetes? *

Yes No

Diabetes at any age with complications of Retinopathy (eye), Nephropathy (kidney), Neuropathy (nerve), Peripheral Vascular Disease (PVD or PAD) or amputation? *

Yes No

In the past 12 months, has the Proposed Insured applied for or received disability, hospital or medical benefits from any insurance company, government, military, employer, or other source (other than for maternity, fractures, spinal or back disorders or joint replacement)? *

Yes No

In the past 5 years, has the Proposed Insured (i) been hospitalized, or (ii) received treatment for, or (iii) been advised by a member of the medical profession to seek treatment for any other health condition (other than for routine physical checkups, eye, employment or Federal Aviation Administration (FAA) examinations)? *

Yes No

5

Past 10 Years — Substance Use & Legal History

In the past 10 years, has the Proposed Insured:

Used alcohol to a degree that required treatment or been advised to limit or discontinue its use by a member of the medical profession? *

Yes No

Used or been convicted of possession of unlawful drugs (other than marijuana) or used prescription drugs other than as prescribed in any form? *

Yes No

Been convicted of or currently awaiting trial for a felony? *

Yes No

In the past 5 years, has the Proposed Insured:

Been convicted of driving under the influence of drugs or alcohol, convicted of reckless driving, or convicted of four or more moving violations? *

Yes No

Been hospitalized for high blood pressure or any mental or nervous disorder? *

Yes No

6

Beneficiary Information

List all primary and secondary beneficiaries. For multiple beneficiaries, include each name and their percentage share (must total 100%).

Primary Beneficiaries *

Primary Beneficiaries Date of Birth *

Primary Beneficiaries Relationship to Insured *

Secondary (Contingent) Beneficiaries *

Secondary Beneficiaries Date of Birth *

Secondary Beneficiaries Relationship to Insured *

7

Additional Services & Interests

We offer a full range of insurance and financial products. Let us know what else we can help you with — at no obligation.

Who will be the payor for this policy? *

Insured Other

Would you like a free auto insurance quote? *

Yes No

Would you like a free homeowner insurance quote? *

Yes No

Would you like a free business insurance quote? *

Yes No

Are you interested in learning how you can convert your retirement savings, 401(k), or IRA into a fixed annuity to lock in guaranteed income for retirement — protecting your savings from market risk? *

A fixed annuity can provide guaranteed lifetime income, tax-deferred growth, and protection from market volatility — with no fees in many products.

Yes — please contact me No Maybe — I'd like more information

What type of life insurance are you looking for? *

Not sure? Select your best guess and an Apex advisor will help you determine the right fit during your consultation.

IUL (Indexed Universal Life) — builds cash value tied to market index with downside protection Whole Life — permanent coverage with guaranteed cash value growth Term Life — affordable coverage for a set period (10, 20, or 30 years) Final Expense — smaller whole life policy to cover end-of-life costs Not Sure — I need guidance from an advisor

Would you be interested in Long-Term Care coverage? *

Long-Term Care insurance helps cover the cost of nursing home, assisted living, or in-home care — expenses that health insurance and Medicare typically do not cover.

Yes — please contact me No Maybe — tell me more

Would you be interested in Cancer Protection coverage? *

Cancer protection plans pay a lump-sum cash benefit directly to you upon a cancer diagnosis — helping cover treatment costs, lost income, and out-of-pocket expenses your health insurance may not cover.

Yes — please contact me No Maybe — tell me more

Would you like a free health insurance quote? *

We offer individual and family health insurance plans including ACA marketplace plans, short-term health, and supplemental coverage.

Yes No

Is there anything else we should know, or would you like more information on any other coverage type? *

8

Authorization & Consent

By submitting this application, you authorize Apex Insurance Solutions to obtain and use the information provided, including medical and financial information, for the purpose of obtaining life insurance quotes and coverage on your behalf. Your information is secure, encrypted, and never sold or shared with third parties outside of insurance carrier underwriting purposes.

I agree that Apex Insurance Solutions may contact me by call, text, or email regarding this application. I authorize the release of medical records as necessary for underwriting. I certify that the answers provided are true and complete to the best of my knowledge. Msg & data rates may apply. Reply STOP to opt out.