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(855) 468-8900

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American-Amicable Life Insurance Company Pre-Application Questionnaire.

Hassan Sanders

CEO/National Independent Agent

National Producer Number: 12878572

Toll-Free: (855) 468-8900

Direct: (855) 468-8900

Fax: (888)-506-1532

Email: [email protected]

Website: www.BestBurialPolicy.com

Email *

Proposed Insured (P.I. must be Owner and Payor)

Proposed Insured First Name *

Proposed Insured Middle initial *

Proposed Insured Last Name *

Street Address *

City in which you live in *

State of residence *

Zip Code *

Gender *

Male

Female

Date of Birth (mm/dd/yyyy) *

Age *

State of Birth *

Social Security Number *

Height *

Weight *

Primary Beneficiary Full Legal Name *

Primary Beneficiary Relationship to Proposed Insured *

Contingent Beneficiary Full Legal Name (if none, type "none") *

Do you have existing life insurance or an annuity contract? *

Yes

Company name, amount of coverage? (if none, type "none") *

Will you replace an existing life insurance policy or an annuity? *

Yes

Not Applicable

Physician Name *

City your physician is in. *

State your physician is in *

The phone number for your physician *

Health Information

1. Are you currently hospitalized, confined to a nursing facility, a bed, or a wheelchair due to chronic illness or disease, currently using oxygen equipment to assist in breathing, receiving Hospice Care or home health care, or had an amputation caused by disease, or do you currently have any form of cancer (excluding basal cell skin cancer) diagnosed or treated by a medical professional or do you require assistance (from anyone) with activities of daily living such as bathing, dressing, eating or toileting? *

Yes

2. Have you had or been medically advised to have an organ transplant or kidney dialysis, or have you been medically diagnosed as having congestive heart failure (CHF), Alzheimer’s, dementia, mental incapacity, Lou Gehrig’s disease (ALS), liver failure, respiratory failure, or been diagnosed by a medical professional as having a terminal medical condition or end-stage disease that is expected to result in death in the next 12 months? *

Yes

3. Have you been medically treated or diagnosed by a medical professional as having Acquired Immune Deficiency Syndrome(AIDS), AIDS-related complex (ARC), or any immune deficiency related disorder or tested positive for the human immunodeficiency virus (HIV)? *

Yes

Health Information Part 2

4. Have you ever been medically diagnosed or treated for complications of diabetes, including insulin shock, diabetic coma, retinopathy (eye), nephropathy (kidney), neuropathy (nerve damage/pain), or used insulin prior to age 50? *

Yes

5. Have you ever been medically diagnosed, treated, or taken medication for renal insufficiency, kidney failure, chronic kidney disease, or more than one occurrence of cancer in your lifetime (excluding basal cell skin cancer)? *

Yes

6. Within the past 2 years have you had any diagnostic testing (excluding tests related to Human Immunodeficiency Virus (HIV)), surgery, or hospitalization advised by a medical professional which has not been completed or for which the results have not been received? *

Yes

7. Within the past 2 years have you:

a. been medically diagnosed or treated for angina (chest pain), stroke or TIA, cardiomyopathy, systemic lupus (SLE), cirrhosis, Hepatitis C, chronic hepatitis, chronic pancreatitis, chronic obstructive pulmonary disease (COPD), emphysema, chronic bronchitis, or required oxygen equipment to assist in breathing? *

Yes

b.had a heart attack or aneurysm, or had or been medically advised to have any type of heart, brain, or circulatory surgery(including, but not limited to a pacemaker insertion, defibrillator placement), or any procedure to improve circulation? *

Yes

c. been medically diagnosed, or treated, or taken medication for any form of cancer (excluding basal cell skin cancer)? *

Yes

d. used illegal drugs, abused alcohol or drugs, had or been recommended by a medical professional to have treatment or counseling for alcohol or drug use, or been advised to discontinue use of alcohol or drugs? *

Yes

Health Information Part 3

8. Within the past 3 years have you been medically diagnosed or treated, or hospitalized for:

a. stroke, angina (chest pain), heart attack, aneurysm, heart or circulatory surgery, or any procedure to improve circulation? *

Yes

b. or taken medication for any form of cancer (excluding basal cell skin cancer), emphysema, chronic bronchitis, chronic obstructive pulmonary disease (COPD), ulcerative colitis, cirrhosis, Hepatitis C, or liver disease? *

Yes

c. paralysis of two or more extremities or cerebral palsy, multiple sclerosis, seizures, Parkinson’s disease, or muscular dystrophy? *

Yes

American-Amicable Bank Draft Authorization The Company indicated above is authorized to initiate debit entries to the account indicated below, and the Bank named below is authorized to debit the same to such account. This authority can be terminated by the undersigned at any time by written notification to the Company, provided only that the Company and the bank will have a reasonable opportunity to act on such notification. By signing below, I authorize the Company indicated above and/or their representative to receive information from the banking facility named so my account number and routing number may be verified.

Bank Name *

Payor/Name on Bank Account *

Transit/ABA Number (routing number) *

Account *

Account type *

Checking

Savings

Would you like your draft to coincide with your Social Security payment schedule? *

Yes

Please choose one of the following as your requested draft date (applies to first and future drafts of this account)

Requested Draft Date, If Any (1st-28th) *

If you have a request or notes you would like to add, please use this space.

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1 E. Erie St. Suite 525,

Chicago, IL 60611

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1 E Erie St ste 525 unit, Chicago, IL 60611, USA

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American-Amicable Life Insurance Company Pre-Application Questionnaire.

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