About This Template
This insurance policy application is designed for insurance agents selling life, health, or supplemental insurance products. It collects applicant information, health history, beneficiary designation, coverage details, and premium payment authorization. The form initiates the underwriting process.
What's Included
- Applicant Name & Date of Birth
- Social Security Number
- Address & Contact Information
- Employment Information
- Coverage Type & Amount Requested
- Beneficiary Information
- Contingent Beneficiary
- Health History Questions
- Current Medications
- Tobacco Use
- Driving Record (for some policies)
- Other Insurance Coverage
- Premium Amount & Payment Frequency
- Payment Method Authorization
- Policy Disclosures & Acknowledgments
- Applicant Signature & Date
Key Benefits
Collects all information needed for underwriting
Documents applicant health status at time of application
Legally binding application protects insurance company
Payment authorization enables automatic premium collection
Professional form builds applicant confidence
How to Use This Template
Complete application during sales presentation
Review all health questions with applicant
Verify beneficiary information is accurate
Obtain applicant signature and witness signature
Submit to underwriting within 24 hours
Legal Disclaimer
- •Insurance applications are legally binding contracts
- •Misrepresentation on application can void policy
- •Include required state-specific disclosures
- •Some states require free-look period notification
- •Retain applications for life of policy plus 7 years