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Foresters Plan Right Whole Life Pre-Application

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 First Name *

Middle initial *

Last Name *

Gender *

Male

Female

Street Address *

City *

State *

Zip *

Social Security # *

Home # phone *

Date of Birth (mm/dd/yyyy) *

State & Country of birth *

U.S. Citizen ?

Yes

Drivers License #

E-mail *

Height (ft/in) *

Weight (lbs) *

Within the past 12 months, have you used tobacco, in any form, or another nicotine product? *

Yes

If quit, how long ago did you quit? *

Medical Questions (For purposes of these questions “you” and “your” mean the proposed insured, “diagnosed”, “advised”, “tested”, “referred”, “repaired”, “monitored”, “observed”, “treated” and “treatment” mean by a licensed physician or medical practitioner and “terminal illness” means an illness that would reasonably be expected to cause death within 12 months.)

1. Are you: a) A resident in, or have you been advised to move into, a nursing home or skilled nursing facility? *

Yes

b) Receiving, or have you been advised to receive, skilled nursing care, hospice care, or home healthcare? *

Yes

c) A patient in a hospital or psychiatric facility, or confined to a correctional facility? *

Yes

d) Using a wheelchair or electric scooter due to an ongoing diagnosed illness, medical condition, or disease? *

Yes

e) Requiring help (from anyone) with administering or taking your medications, or with bathing, dressing, eating, or toileting? *

Yes

2. Within the past year (12 months), have you been advised to: a) Use, or have you used, oxygen equipment to assist with breathing (excluding use for sleep apnea)? *

Yes

b) Have, or have you had kidney dialysis? *

Yes

c) Have surgery, a medical procedure, hospitalization, or have you been referred for a check-up or consultation with a doctor or medical specialist, which has not yet been started, completed, or for which results are not known? *

Yes

d.Have a diagnostic test, or have you been referred to get a lab test, which has not yet been started, completed, or for which results are not known (excluding tests related to the Human Immunodeficiency Virus (HIV))? *

Yes

3. Within the past year (12 months), have you consulted a physician for, been diagnosed with, or received or been advised to receive treatment or medication for, unexplained weight loss greater than 10 pounds? *

Yes

4. Have you ever received, or been advised to receive, an organ or bone marrow transplant, or had an amputation that you were advised was due to complications of diabetes? *

Yes

5. Have you ever been diagnosed with, or received or been advised to receive treatment or medication for: a) Cardiomyopathy, Congestive Heart Failure (CHF), Pulmonary Hypertension, or any other type of heart failure or heart muscle disease? *

Yes

b) Amyotrophic Lateral Sclerosis (ALS), or a terminal illness or end-stage disease?

Yes

c) Alzheimer’s disease, dementia, or memory loss? *

Yes

d) Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or tested positive for HIV? *

Yes

6. Have you ever been diagnosed with more than one occurrence of the same or different type of cancer, or do you currently have cancer (the term “cancer” excludes basal cell skin cancer)? *

Yes

7. Have you ever been diagnosed with diabetes and have also been diagnosed with, or advised to receive treatment for: a) Retinopathy (problems with your eyesight)? *

Yes

b) Nephropathy (kidney disease or kidney damage)? *

Yes

c) Peripheral Neuropathy (nerve damage or numbness)? *

Yes

8. Within the past 2 years (24 months), have you been hospitalized for 48 hours or more that you were advised was due to diabetes? *

Yes

9. Within the past 2 years (24 months), have you been diagnosed with, or received or been advised to receive treatment for: a) Alcohol or drug abuse, or have you used illegal drugs? *

Yes

10. Within the past year (12 months), have you been diagnosed with having: a) A heart attack, stroke, or Transient Ischemic Attack (TIA/mini-stroke)?

Yes

11. Within the past year (12 months), have you been advised to have, or have you had, a pacemaker or defibrillator implant, cardioversion treatment, or any other type of heart or circulatory procedure? *

Yes

12. Within the past 3 years (36 months), have you been diagnosed with cancer, or received or been advised to receive chemotherapy, radiation, or any other type of treatment for cancer (the term “cancer” excludes basal cell skin cancer)? *

Yes

13. Have you ever been diagnosed with, or received or been advised to receive treatment or medication for: a) Parkinson’s disease or Systemic Lupus (SLE)? *

Yes

b) Hepatitis B or C, cirrhosis of the liver, or any other type of liver disease or condition? *

Yes

c) Chronic kidney disease, chronic renal insufficiency, or any other type of kidney disease or condition (excluding kidney stones)? *

Yes

d) Chronic Obstructive Pulmonary Disease (COPD), chronic bronchitis, emphysema, or any other type of chronic lung disease or ongoing respiratory condition (excluding asthma or sleep apnea)? *

Yes

14. Within the past 2 years (24 months), have you been diagnosed with having: a) A heart attack, stroke, or Transient Ischemic Attack (TIA/mini-stroke)? *

Yes

b) Angina, or have you taken medication for angina? *

Yes

15. Within the past 2 years (24 months), have you been advised to have, or have you had, a pacemaker or defibrillator implant, cardioversion treatment, or any other type of heart or circulatory procedure? *

Yes

Financial institution information

Type of Account: *

Checking

Savings

Name of financial institution: *

Routing Transit # (9 digits): *

Account # (maximum 17 digits): *

Name of Payor *

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1 E. Erie St. Suite 525,

Chicago, IL 60611

Monday – Friday (9am-6pm)

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

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