form-1 - UFC4WEALTH

Name of Employer

Length of Employement?

Name (First Name)

Name (Middle Name)

Name (Last Name)

Date of Birth

SSN

Gender

Height

Weight

Country of Birth

US Citizen

If No, Green Card Number or Visa Type

Driver License Number / Exp.Date

DL State

Residential Address

Apt

City

State

Zip Code

Prefered Phone

Phone Number

Best time to contact you?

Secondary Phone

Phone Number

Best time to contact you?

Email Address

Annual Income

Household Income

Net Worth

Household Net Worth

Face Amount

Plan Product

Mode of Premium

Primary Beneficiary
First Name

Primary Beneficiary
Middle Name

Primary Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Second Beneficiary
First Name

Second Beneficiary
Middle Name

Second Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Third Beneficiary
First Name

Third Beneficiary
Middle Name

Third Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Fourth Beneficiary
First Name

Fourth Beneficiary
Middle Name

Fourth Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Fifth Beneficiary
First Name

Fifth Beneficiary
Middle Name

Fifth Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Sixth Beneficiary
First Name

Sixth Beneficiary
Middle Name

Sixth Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Seventh Beneficiary
First Name

Seventh Beneficiary
Middle Name

Seventh Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Eighth Beneficiary
First Name

Eighth Beneficiary
Middle Name

Eighth Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Ninth Beneficiary
First Name

Ninth Beneficiary
Middle Name

Ninth Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Tenth Beneficiary
First Name

Tenth Beneficiary
Middle Name

Tenth Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Eleventh Beneficiary
First Name

Eleventh Beneficiary
Middle Name

Eleventh Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Twelfth Beneficiary
First Name

Twelfth Beneficiary
Middle Name

Twelfth Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Thirteenth Beneficiary
First Name

Thirteenth Beneficiary
Middle Name

Thirteenth Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Fourteenth Beneficiary
First Name

Fourteenth Beneficiary
Middle Name

Fourteenth Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Fifteenth Beneficiary
First Name

Fifteenth Beneficiary
Middle Name

Fifteenth Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Sixteenth Beneficiary
First Name

Sixteenth Beneficiary
Middle Name

Sixteenth Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Seventeenth Beneficiary
First Name

Seventeenth Beneficiary
Middle Name

Seventeenth Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Eighteenth Beneficiary
First Name

Eighteenth Beneficiary
Middle Name

Eighteenth Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Nineteenth Beneficiary
First Name

Nineteenth Beneficiary
Middle Name

Nineteenth Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Twentieth Beneficiary
First Name

Twentieth Beneficiary
Middle Name

Twentieth Beneficiary
Last Name

Percentage

Address

Phone Number

Relationship?

SSN

Date of Birth

Have you used any type of product(s) containing tobacco or nicotine in the last 5 years?

If yes, Type? Frequency? Last Use?

Father's age, If living

If deceased, age and cause of death?

Mother's age, If living

If deceased, age and cause of death?

Do you have any in-force life insurance or annuity contracts including long term care insurance or riders?

Will in-force coverage be replaced?

Within the past 5 years have you worked less than full time, received or applied for disability or worker's compensation?

During the last 5 years have you plead guilty to or been convicted of any moving vehicle violations or DUI or have you had a suspended license?

If Yes, Explain

Have you ever been convicted of a felony or misdemeanor?

If Yes, Explain

Have you been or are you currently involved in any bankruptcy proceedings that have not been discharged?

If Yes, Explain

Do you participate in any motor sport, automobile, motorcycle, boat or marathon racing; scuba, skin, sport or sky diving; sports in which you compete against other individuals; parachuting; or hang gliding; BASE (parachute jumping from Buildings, Antennas, Spans (bridges) or Earth) or bungee cord jumping; big game hunting; mountain climbing; cave exploring; rodeos or snowmobiling?

If Yes, Explain

Do you participate in any aviation activity other than as a fare paying passenger?

If Yes, Explain

In the past 10 years have you EVER been diagnosed or treated by a licensed member of the medical profession or taken medication for:

1.) Any disease or abnormal condition of the heart, circulatory system, high blood pressure, high cholesterol, irregular heartbeat, murmur, rheumatic fever, coronary artery disease, chest pain, angina, transient ischemic attack or stroke?

2.) Any disease of the lungs or respiratory system, sleep apnea, emphysema, asthma, bronchitis, tuberculosis, shortness of breath, allergies or disorder of the nose or throat?

3.) Any digestive system disease, including ulcer, chronic indigestion, liver, stomach, intestine or pancreas disorder, hepatitis, cirrhosis, jaundice, esophagus disorder, gallbladder disorder, or colon disorder?

4.) Any disorder of the nervous system, dizzy spells, epilepsy, convulsions, paralysis, unconsciousness, brain or eye disorders, or headaches?

5.) Any spine, hip, knee, shoulder, back, bones, muscles, arthritis, rheumatism, joints, skin, thyroid, gout or other gland disorder?

6.) Any urinary system disease including protein, sugar or blood in urine, kidney infection or stones, disorder or disease of the breast, prostate or bladder, or pelvic organs?

7.) Any depression, anxiety, bipolar, schizophrenia, attention deficit disorder (ADD), or any other developmental or psychological condition including memory loss, Alzheimer's, Dementia, or Post Traumatic Stress Disorder (PTSD)?

8.) Any anemia, hemophilia or disorders of the blood other than Acquired Immune Deficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV)?

9.) Any cancer, polyp, other tumors?

10.) Diabetes or high blood sugar?

11.) In the past 10 years has a licensed member of the medical profession diagnosed or treated you for a disease or other medical condition that resulted in you having an amputation?

12.) In the past 10 years has a licensed member of the medical profession diagnosed or treated you for Ataxia, transverse Myelitis, Myasthenia Gravis, Autoimmune Disorder such as Lupus, Blindness, or Post Polio Syndrome?

13.) In the past 10 years has a licensed member of the medical profession diagnosed or treated you for Parkinson's disease, Muscular Dystrophy, Huntington's Chorea, Motor Neuron Disease, Lou Gehrig's Disease (ALS), or Multiple Sclerosis?

14.) In the past 10 years have you used marijuana, cocaine, heroin, or any other illicit drug or controlled substance, been advised by a licensed member of the medical profession to discontinue or reduce alcohol or drug intake, used drugs not prescribed by a physician, or been a member of a support group such as NA or AA?

15.) Have you been tested positive for exposure to the HIV infection or been diagnosed as having ARC or AIDS caused by the HIV infection or other sickness or condition derived from such infection?

16.) To the best of your knowledge and belief has a parent or sibling been diagnosed or treated by a health professional for cancer, heart disease, Huntington's Disease or polycystic kidney disease?

17.) Do you have any pending appointments with any medical professional?

Details to any "YES" answers. Indicate Question #, Date of Onset, Treatment, Physician(s) seen

Within the past 5 years have you:

1.) Consulted with a physician other than your personal physician or had x-rays, electrocardiograms, heart catheterization or other diagnostic tests, except those related to the Human Immunodeficiency Virus (AIDS Virus)?

2.) Been admitted to a hospital, or plan to enter a hospital within the next 30 days, or been advised by a licensed member of the medical profession to enter a hospital for observation, operation or treatment of any kind?

If you answered yes to any of the previous questions, please provide details:

Do You Currently:

1.) Use or require the use of any mechanical or medical devices such as: a wheelchair, walker, multi-prong cane, hospital bed, dialysis machine, respirator oxygen, motorized cart or stair lift?

2.) Need help, assistance or supervision for: bathing, eating, dressing, toileting, walking, transferring, or maintaining continence?

3.) Need help, assistance or supervision in: taking medication, doing housework, laundry, shopping or meal preparation?

4.) Have you ever been diagnosed with, consulted a medical professional for, or been treated or advised treatment for: Falls, Paralysis, Numbness, Tremors, Imbalance, or any condition which causes limited motion?

5.) Have you ever been diagnosed with, consulted a medical professional for, been treated or advised to be tested or treated for memory loss, confusion, amnesia?

If you answered yes to any of the previous questions, please explain:

Are you taking any medications?

If yes, provide condition treated, dosage, and prescribing physician:

Do you have a primary care physician? (Please provide Name, Phone Number and Address)

Date and reason for last visit?

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