Life Insurance Information Request0%
Henry AsherbrannerFinancial Advisorhenry.asherbranner@cs-ag.com

Life Insurance Information Request

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22sections
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ANSWER EVERY QUESTION. An incomplete application cannot be submitted to a carrier.

Proposed Insured — Full Name*
Date*
Section 01

Personal Details

First Name*
M.I.
Last Name*
Suffix
Date of Birth*
Age*
Gender*
Social Security Number*
Marital Status*
Place of Birth — City & State/Province*
Birth Country*
Section 02

Residence Address

Street Address*
Street Address Line 2
City*
State*
Zip Code*
Years at This Address*
State Where This Application Will Be Signed*

Is the mailing address the same as the residence address?*

Mailing Address — only if different from the residence
Street Address*
Street Address Line 2
City*
State*
Zip Code*
Section 03

Contact Information

Email*
Primary Phone*
Best Time to Reach You
Home Phone
Mobile Phone
Work Phone
Section 04

Identification & Citizenship

Government ID Type (Driver’s License / State ID / Passport / Military ID)*
ID Number*
Issuing State or Country*
Expiration Date*

Is the Proposed Insured a U.S. citizen?*

Only if not a U.S. citizen
Country of Citizenship*
Visa Type / Immigration Status*
Date of Entry to U.S.*
Years Residing in U.S.*
Section 05

Employment & Income

Retired or a homemaker? Enter that as the Occupation and write “N/A” in the employer fields.

Occupation*
Employer Name*
Employer Address*
City*
State*
Zip Code*
Years With This Employer*
Years in This Occupation*
Duties Performed*

Is the Proposed Insured self-employed or a business owner?*

If yes — entity name, ownership %, and years in business*
Annual Earned Income ($/yr)*
Total Household Income ($/yr)*
Net Worth ($)*
Section 06

Policy Owner

Will the Proposed Insured be the Owner of this policy?*

Owner — complete only if different from the Proposed Insured
Owner Type (Individual / Trust / Business / Other)*
Full Legal Name*
Relationship to Proposed Insured*
Date of Birth*
Social Security Number / TIN*
Citizenship*
Address*
City*
State*
Zip Code*
Email*
Phone*

State the insurable interest — why this Owner has a legitimate interest in the life of the Proposed Insured.*

If the Owner is a Trust or a Business
Trust or Entity Legal Name*
Date of Trust / State of Formation*
TIN / EIN*
Trustee(s) or Authorized Signer*
Title of Authorized Signer*
Section 06b

Contingent Owner

Complete only if you want a second owner named should the first predecease the insured.

Full Name
Date of Birth
Relationship
Address
Section 07

Beneficiary Information

Percentages must total 100% within the primary tier, and 100% within the contingent tier. A Social Security Number is optional but will speed any future claim.

Primary Beneficiary 1
First Name*
M.I.
Last Name*
Suffix
Relationship to Proposed Insured*
Date of Birth*
% Share*
Social Security Number (optional)
Address (if different from the Proposed Insured)
Phone
Email
Beneficiary Type (Individual / Trust / Estate / Charity / Entity)*
Per Stirpes or Per Capita?*
Primary Beneficiary 2
First Name*
M.I.
Last Name*
Suffix
Relationship to Proposed Insured*
Date of Birth*
% Share*
Social Security Number (optional)
Address (if different from the Proposed Insured)
Phone
Email
Beneficiary Type (Individual / Trust / Estate / Charity / Entity)*
Per Stirpes or Per Capita?*
Primary Beneficiary 3
First Name*
M.I.
Last Name*
Suffix
Relationship to Proposed Insured*
Date of Birth*
% Share*
Social Security Number (optional)
Address (if different from the Proposed Insured)
Phone
Email
Beneficiary Type (Individual / Trust / Estate / Charity / Entity)*
Per Stirpes or Per Capita?*
Contingent Beneficiary 1
First Name*
M.I.
Last Name*
Suffix
Relationship to Proposed Insured*
Date of Birth*
% Share*
Social Security Number (optional)
Address (if different from the Proposed Insured)
Phone
Email
Contingent Beneficiary 2
First Name*
M.I.
Last Name*
Suffix
Relationship to Proposed Insured*
Date of Birth*
% Share*
Social Security Number (optional)
Address (if different from the Proposed Insured)
Phone
Email
Section 08

Existing Insurance

Does the Proposed Insured have existing life insurance or annuity contracts in force or applied for?*

If yes — list every policy in force
Insurance CompanyPolicy NumberFace Amount $Year IssuedType of CoverageReplacing? (Y/N)

Within the past 12 months, has the Proposed Insured applied for — or is any application currently pending for — life or disability insurance with any company?*

If yes — company, date applied, amount, and current status*

Is this application intended to replace or change any life insurance or annuity contract in force with this or any other company?*

Is the Proposed Insured or Owner considering using funds from an in-force life insurance or annuity contract to fund this policy (a 1035 exchange)?*

If yes — the policy being exchanged
Current Cash Surrender Value ($)*
Cost Basis ($)*
Outstanding Loan Balance ($)*
Surrender Charge Remaining?*
Section 09

Payment Information

Payor — only if someone other than the Proposed Insured or Owner will pay
Payor — Full Name*
Relationship to Proposed Insured*
Payor Address*

Primary source of funds for the premium*

Salary or wages, savings, sale of an investment, 1035 exchange, retirement account, gift, inheritance, business proceeds, other — please specify

Section 09b

Bank Draft Details

Attach a voided check.

Name on Bank Account*
Full Name of Bank*
Preferred Draft Day (1–28)*
Routing Number*
Account Number*
Account Type (Checking / Savings)*
Section 10

Underwriting Questions — Legal, Financial and Lifestyle

Has the Proposed Insured ever declared personal or business bankruptcy?*

If yes, please explain in full*

Within the past 5 years, has any company declined, postponed, rated, refused to reinstate, or modified any insurance on the life of the Proposed Insured?*

If yes, please explain in full*

Has the Proposed Insured ever pled guilty to, or been convicted of, any felony or misdemeanor, or are any such charges currently pending?*

If yes, please explain in full*

Within the past 5 years has the Proposed Insured had a driver’s license suspended or revoked, or pled guilty to or been convicted of a moving traffic violation or a DUI/DWI?*

If yes, please explain in full*

Is the Proposed Insured a member, or has entered into a written agreement to become a member, of the military (including the Reserve and National Guard)?*

If yes, please explain in full*

In the next 2 years, does the Proposed Insured intend to travel or reside outside the United States or Canada?*

If yes, please explain in full*

Other than as a fare-paying passenger on a scheduled airline, has the Proposed Insured flown within the last 3 years, or plan to fly within the next 2 years?*

If yes, please explain in full*

Within the last 3 years, has the Proposed Insured engaged in — or plan within the next 2 years to engage in — skin or scuba diving, powered racing, hang gliding, parasailing, mountain or rock climbing, sky diving or parachuting, or other hazardous avocations?*

If yes, please explain in full*

Within the last 5 years, has the Proposed Insured worked less than full time, or received or applied for disability or worker’s compensation?*

If yes, please explain in full*

Has the Proposed Insured been offered any cash incentive or other consideration, such as free insurance, as an inducement to apply for or become insured under this policy?*

If yes, please explain in full*

Has the Proposed Insured been involved in any discussions about the possible sale or transfer of this policy to an unrelated third party, such as a life settlement company or investor group?*

If yes, please explain in full*
Section 11

Primary Health Care Provider

Physician First Name*
Physician Last Name*
Specialty*
Healthcare Facility Name*
Phone Number*
Street Address*
City*
State*
Zip Code*
Date Last Seen*
Reason for the Last Visit*
Section 12

Build — Height & Weight

Height — Feet*
Height — Inches*
Weight (lbs)*

Has the Proposed Insured gained or lost 10 pounds or more in the past 12 months?*

If yes — how much, and the reason*
Section 13

Tobacco & Nicotine Use

Within the past 5 years, has the Proposed Insured used tobacco or nicotine in any form?*

If yes — list each product (cigarettes, cigars, pipe, chewing tobacco, snuff, vape or e-cigarette, patch, gum), how much, how often, and the date last used*
Section 14

Alcohol

Has the Proposed Insured ever received treatment, counseling, or advice from a medical professional regarding alcohol use?*

If yes, please explain in full*
Average Alcoholic Drinks Per Week*
Any change in the past 5 years? Please describe*
Section 15

Drugs

Has the Proposed Insured ever used cocaine, heroin, amphetamines, barbiturates, hallucinogens, marijuana, or any controlled substance except as prescribed by a physician?*

If yes, please explain in full*

Has the Proposed Insured ever received treatment, counseling, or advice from a medical professional regarding drug use?*

If yes, please explain in full*
Section 16

Family History

RelativeLiving? (Y/N)Age Now, or Age at DeathCause of Death (if deceased)
Mother
Father

Has a parent or sibling been diagnosed before age 60 with heart disease, stroke, cancer, diabetes, kidney disease, or any hereditary disorder?*

If yes — specify the relative, the condition, and the age at onset*
Section 17

Medical History

For each “Yes,” tick every condition that applies. The online form then asks a few short questions about each one; on paper, fill in a Condition Detail block for each.

Has the Proposed Insured ever had a disease or disorder of the heart or circulatory system?*

Tick every one that applies.

Has the Proposed Insured ever had a disease or disorder of the blood or immune system? (other than HIV)*

Tick every one that applies.

Has the Proposed Insured ever had a disease or disorder of the urinary system?*

Tick every one that applies.

Has the Proposed Insured ever had an abnormal growth, cyst, tumor, cancer or melanoma?*

Tick every one that applies.

Has the Proposed Insured ever had a disease or disorder of the endocrine or hormone system?*

Tick every one that applies.

Has the Proposed Insured ever had a disease or disorder of the respiratory system?*

Tick every one that applies.

Has the Proposed Insured ever had a disease or disorder of the nervous system, including psychological or psychiatric care?*

Tick every one that applies.

Has the Proposed Insured ever had a disease or disorder of the digestive system?*

Tick every one that applies.

Has the Proposed Insured ever had a disease or disorder of the muscle, skin, bone or joint?*

Tick every one that applies.

Has the Proposed Insured ever had a disease or disorder of the eyes, ears, nose or throat?*

Tick every one that applies.

Has the Proposed Insured ever had a disease or disorder of the reproductive system?*

Tick every one that applies.

Has the Proposed Insured ever been diagnosed with a progressive neurological or auto-immune disease?*

Tick every one that applies.

Section 18

Medical History — Additional

Has the Proposed Insured ever had, been diagnosed with, tested positive for, or been given medical advice for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or Human Immunodeficiency Virus (HIV)?*

If yes, please explain in full*

A separate HIV testing consent form may be required in your state.

Is the Proposed Insured currently pregnant?*

If yes — expected due date*
Section 19

General Medical

Apart from anything already listed in the Medical History section, is the Proposed Insured taking — or has taken within the last 12 months — any prescription medication, over-the-counter drug (including aspirin), or herbal supplement?*

One for each medication, including anything bought over the counter.

Within the past 5 years, has the Proposed Insured been admitted to a hospital or seen in an Emergency Department?*

One for each stay or visit.

Within the past 5 years, has the Proposed Insured consulted any physician other than the primary care physician, including x-rays, tests, or procedures?*

One for each provider.

Does the Proposed Insured use or require any mechanical or medical device such as a wheelchair, walker, multi-prong cane, hospital bed, dialysis machine, respirator, oxygen, motorized cart, or stair lift?*

If yes — which device, since when, and the outlook*

Does the Proposed Insured need help, assistance, or supervision with bathing, eating, dressing, toileting, walking, transferring, or maintaining continence?*

If yes — with what, since when, and the outlook*

Does the Proposed Insured need help, assistance, or supervision with taking medication, housework, laundry, shopping, or meal preparation?*

If yes — with what, since when, and the outlook*

Has the Proposed Insured ever been diagnosed with a terminal illness or been given a life expectancy of less than 12 months?*

If yes, please explain in full*

Does the Proposed Insured currently have any pending appointments with any health care provider?*

If yes, please explain in full*
Section 20

Remarks

Use this space for anything that did not fit above. Say which section each note is about.

Finished

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The financial professionals of Cornerstone Advisor Group are Investment Adviser Representatives and investment advisory services are offered solely by ESI Financial Advisors, 10472 Armstrong Street, Fairfax VA 22030, (866) 868-1492. Cornerstone Advisor Group is independent of ESI Financial Advisors.
10472 Armstrong Street, Fairfax Virginia 22030www.cornerstoneadvice.com866-868-1492CAG-LIFE-IR v2026.08