Assurity Term Life Application Bridge

Insurance By Heroes · Assurity

Finish your application details

A supplement to your prequalification form.

Step 1 of 6 - Your remaining details

URL
This field is for validation purposes and should be left unchanged.
Your remaining details
This supplement collects the remaining details for your Assurity application. We’ll use your name and date of birth to match these details with your prequal. Your agent will review everything with you before the carrier application is signed.
Your name(Required)
Use the same first and last name as your prequal.
First Last
Date of birth(Required)
Used to match this supplement to your prequal.
MM
DD
YYYY
Social Security number(Required)
Enter all nine digits.
Are you a U.S. citizen?(Required)
- Yes
- No
Do you have permanent resident (green card) status?(Required)
Permanent resident card number(Required)
Enter your permanent resident card number.
Country of birth(Required)
State of birth(Required)
Country of birth outside the U.S.(Required)
Do you have a valid driver’s license?(Required)
Driver’s license number(Required)
Driver’s license issuing state(Required)
Best day and time for your telephone interview(Required)
Include your time zone.
Do you use tobacco?(Required)
- Yes
- No
List all types of tobacco and/or nicotine that you use.(Required)
Date of last use
MM
DD
YYYY
Amount used per day(Required)

Employment and signing
Occupation(Required)
Duties(Required)
Describe your day-to-day job duties.
Gross monthly income(Required)
Before taxes and deductions.
Please enter a number greater than or equal to 0.
Application signed by(Required)
Policy ownership
Will you be the policyowner?(Required)
Policyowner type(Required)
Owner’s relationship to you(Required)
Individual owner’s full legal name(Required)
First Middle Last
Individual owner’s date of birth(Required)
MM
DD
YYYY
Individual owner’s Social Security number(Required)
Individual owner’s country and state of birth(Required)
Full legal trust or corporation name(Required)
Trust or corporation tax ID number(Required)
Date of trust(Required)
MM
DD
YYYY
Trustee or authorized corporate representative(Required)
First Middle Last
Representative’s Social Security number(Required)
Required by Assurity for electronic signing.
Policyowner’s address(Required)
Street Address Address Line 2 City State ZIP Code
Policyowner or authorized signer email(Required)
Enter Email Confirm Email
Will there be a contingent owner?(Required)
Contingent owner type(Required)
Contingent owner’s full legal name(Required)
For an individual, include first, middle and last name. For a trust or corporation, use its legal name.
Contingent owner’s relationship to you(Required)

Beneficiaries
Primary beneficiaries receive the benefit first. Contingent beneficiaries receive it if no primary beneficiary survives you. Each group must total 100%. Add a separate row for each beneficiary.

Primary beneficiaries(Required)

For a person, enter their SSN and birth date. For a trust or corporation, enter its tax ID; trusts also need the trust date. For an estate or children equally, enter that designation; leave inapplicable identifiers and dates blank.

Full legal name (include middle name)	Relationship to insured / entity type	SSN or tax ID	Birth date or trust date (MM/DD/YYYY)	Share (%)

Would you like contingent beneficiaries?(Required)

Contingent beneficiaries(Required)

Full legal name (include middle name)	Relationship to insured / entity type	SSN or tax ID	Birth date or trust date (MM/DD/YYYY)	Share (%)

Is any beneficiary a trust?(Required)
Beneficiary trustees(Required)
Trust beneficiary name Trustee first and last name Trustee street address City State ZIP code

Policy details and riders
Your agent will use your prequal and current quote for the term and coverage amount. Rider requests below are subject to availability and agent review.
Have you entered into any agreement to assign or sell this policy?(Required)
Do you intend to sell the policy after it is issued?(Required)
Have you had a life-expectancy or health examination related to this application or a life-settlement option contract?(Required)
Explain the agreement, intended sale or examination(Required)
Would you like your agent to review additional riders?(Required)
Disability Waiver of Premium Rider(Required)
Endowment Benefit / Return of Premium Rider(Required)
Accelerated Benefits Rider, where available(Required)
Request Critical Illness Rider?(Required)
Critical illness benefit amount requested(Required)
Please enter a number greater than or equal to 0.
Do you currently have comprehensive health insurance?(Required)
Health coverage situation(Required)
Request Monthly Disability Income Rider?(Required)
Monthly disability benefit requested(Required)
Please enter a number greater than or equal to 0.
Request Accident-Only Disability Income Rider?(Required)
Monthly accident-only disability benefit requested(Required)
Please enter a number greater than or equal to 0.
Request Children’s Term Insurance Rider?(Required)
Children’s rider units requested(Required)
Your agent will confirm available units and coverage per unit.
Please enter a number greater than or equal to 1.

Children to include(Required)

The carrier identifies each person on this rider as a child of the proposed insured.

Full legal name (first, middle, last)	Sex	Date of birth (MM/DD/YYYY)	Height (feet and inches)	Weight (pounds)	Social Security number	Country and state of birth	Lives with proposed insured? (Yes or No)

Request Other Insured Term Rider?(Required)
Other insured
Other insured’s full legal name(Required)
First Middle Last
Other insured’s date of birth(Required)
MM
DD
YYYY
Other insured’s gender(Required)
Other insured’s Social Security number(Required)
Relationship to proposed insured(Required)
Height (feet and inches)(Required)
Weight (pounds)(Required)
Please enter a number greater than or equal to 1.
Country and state of birth(Required)
Other insured’s email address(Required)
Enter Email Confirm Email
Does the other insured live with the proposed insured?(Required)
Other insured’s home address(Required)
Street Address Address Line 2 City State ZIP Code
Is the other insured a U.S. citizen?(Required)
Does the other insured have permanent resident status?(Required)
Other insured’s permanent resident card number(Required)
How long has the other insured lived in the U.S.?(Required)
Does the other insured have a valid driver’s license?(Required)
Other insured’s license number(Required)
Other insured’s license issuing state(Required)
Is the other insured self-employed?(Required)
Other insured’s employer or establishment name(Required)
Other insured’s occupation and duties(Required)
Other insured’s monthly income(Required)
Enter net income if self-employed; otherwise enter gross income.
Please enter a number greater than or equal to 0.
Other insured’s requested coverage amount(Required)
Please enter a number greater than or equal to 0.
Has the other insured ever used tobacco, nicotine products, patches or gum?(Required)
Other insured’s product types(Required)
Other insured’s last use date(Required)
MM
DD
YYYY
Other insured’s amount per day(Required)
Who will sign for the other insured?(Required)
Other insured’s attorney-in-fact name(Required)
First Middle Last
Other insured’s attorney-in-fact SSN(Required)
Other insured’s attorney-in-fact email(Required)
Enter Email Confirm Email
Legal description of other insured’s signer(Required)
Request Critical Illness Rider for the other insured?(Required)
Other insured’s critical illness amount(Required)
Please enter a number greater than or equal to 0.
Does the other insured have comprehensive health insurance?(Required)
Request Monthly Disability Income Rider for the other insured?(Required)
Other insured’s monthly disability benefit(Required)
Please enter a number greater than or equal to 0.
Request Accident-Only Disability Income Rider for the other insured?(Required)
Other insured’s monthly accident-only disability benefit(Required)
Please enter a number greater than or equal to 0.
Existing insurance
Is any proposed insured currently negotiating for other insurance coverage?(Required)
Pending coverage details(Required)
Include the insured, insurer, type of coverage, amount and application status.
Does any proposed insured have insurance coverage in force?(Required)
Will this insurance replace, modify or borrow against existing or pending coverage?(Required)
Are you considering discontinuing premiums, surrendering, forfeiting, assigning to an insurer, or terminating existing insurance?(Required)
Will funds from existing insurance pay premiums on this policy?(Required)
Reason for the replacement or change(Required)
What is the purpose of the replacement?(Required)
Other replacement purpose(Required)

Existing policy details(Required)

Insurer name	Policy type (life, disability, critical illness)	Contract or policy number	Issue date (MM/DD/YYYY)	Individual or group	Owner full name	Insured full name	Face amount / monthly benefit	Replaced, financed or neither

Disability-policy additional details
Policy number Benefit period Coordinates with Social Security? Employer paid?
Additional replacement details
If known, include insurer address/home-office location, existing agent, optional benefits and planned exchange (lapse, loan or surrender). Your agent will complete any state-specific replacement notices.
Would you like a written summary statement from your existing insurer?(Required)

Premium payment
Payment method: recurring bank draft.
Preferred premium frequency(Required)
Will you be the premium payer?(Required)
Premium payer’s full legal name(Required)
First Middle Last
Payer’s relationship to you(Required)
Premium payer’s address(Required)
Street Address Address Line 2 City State ZIP Code
Premium payer’s phone number(Required)
Financial institution name(Required)
Account type(Required)
Bank routing number(Required)
Bank account number(Required)
Preferred bank draft day(Required)
Does the bank account belong to you?(Required)
Is this a business account?(Required)
Authorized account holder’s full name(Required)
Account holder’s relationship to you(Required)
Business account name(Required)
Authorized officer’s title(Required)
Account holder or business address(Required)
Street Address Address Line 2 City State ZIP Code
Authorized signer’s Social Security number(Required)
Assurity requires this for electronic signing.
Authorized account signer’s email(Required)
Enter Email Confirm Email
Authorized account signer’s phone(Required)
Premiums will be paid by recurring bank draft. These details are for your agent to prepare the initial and recurring bank drafts. This supplement does not debit your account or authorize a withdrawal; you will review and sign the carrier’s bank-draft authorization separately.

Trust beneficiary name	Trustee first and last name	Trustee street address	City	State	ZIP code

Policy number	Benefit period	Coordinates with Social Security?	Employer paid?

Finish your application details

Step 1 of 6 - Your remaining details

Your remaining details

Employment and signing

Policy ownership

Beneficiaries

Policy details and riders

Other insured

Existing insurance

Premium payment

Final details