New Application Please only complete this form after speaking with Blake or a member of his team. This is not an application for life insurance. This information is helpful documentation for the life insurance application process. Name* First Last Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How long (years) have you lived at this address:*Please enter a number from 0 to 30.Email* Cell Phone*Date of Birth* MM slash DD slash YYYY Sex* Male Female Social Security Number* (This information is transmitted securely and is not retained by Brogan Wealth Strategies)Driver's License Number* Driver's License Expiration Date* Driver's License Issued by*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCountry of Birth*AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweState of Birth*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAre you a U.S. Citizen?* Yes No Income* Enter the gross earned income that you expect to receive over the next 12 months. This number does not need to be exact but should be a reasonable representation of what you expect to earn.Height* Weight* Employment InformationEmployer Name:* Length of Employment* Occupation/Position:* Duties FamilyMarital Status: Name of Spouse: How many children: Listed BeneficiariesPlease list who you would like to be listed as the beneficiaries of this policy at the time of application. This may be changed by you at any time once the policy is in force. Primary Beneficiary*(Most typically a spouse) Your Relationship to Beneficiary* Beneficiary Date of Birth* Existing Life InsuranceTo the best of your knowledge, please share any current and in-force life insurance policies where you are the insured, list the company, amount of death benefit and type (term, whole or universal).PolicyCompany NameAmount of Death BenefitType Ever applied for insurance and were rated or declined? Yes No Please provide more detailsNon-MedicalIn the past year, used any product containing nicotine? Yes No Please provide more detailsUsed, in either synthetic or natural form, marijuana products in the last 12 months? Yes No Please provide more detailsOn active or inactive duty with any branch of the Armed Forces, National Guard or Reserve Unit? Yes No Please provide more detailsWithin the past 2 years, engaged or plan to engage in flying as a pilot or crew member? Yes No Height*Weight*Within the past 2 years, engaged in racing, parachuting, or scuba diving or have intention of doing so within the next 2 years? Yes No Please provide more detailsEver had a driver’s license suspended or revoked or, within the last 5 years, been convicted of or pled no contest to reckless or negligent driving or driving under the influence of alcohol or drugs? Yes No Please provide more detailsEver been convicted of, pled guilty or have current charges pending for, a felony or misdemeanor? Yes No Please provide more detailsWithin the next year, intend to travel or live outside the U.S. or Canada? Yes No Please provide more detailsWithin the past 5 years, been declined, withdrawn, or postponed for insurance or had a policy issued other than applied for? Yes No Please provide more detailsCurrently receiving, or within the past 5 years received or applied for disability benefits, including Worker’s Compensation, Social Security Disability, or other form of disability insurance? Yes No Please provide more detailsEver used illegal or other habit forming drugs, except as prescribed by a physician, or been advised by a physician to discontinue the use of alcohol and/or non-prescribed drugs? Yes No Please provide more detailsBased on what you currently know about life insurance underwriting, do you expect any difficulty getting approved for life insurance?Do you have a Personal Physician?* Yes No Name of Your Personal Physician* Physician Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician Telephone Number Please Note: On the application you will see the amount of Death Benefit being applied for. Please note this will likely be more than you intend to eventually have put in force. What we list on the application is the maximum for which you will be approved. Once approved you can then decide on any lesser amount or up to the maximum.Email Newsletter Subscribe to our Email Newsletter EmailThis field is for validation purposes and should be left unchanged. Δ