LEVEL UP LEADS

CRM SUPPORT

Before submitting a ticket, please note that we don't give access to workflows, campaigns, and triggers.

LEVEL UP LEADS

CRM SUPPORT

Adult Client Information

Together, We Protect What Matters The Most

Our case managers will contact you to help obtain the medical records required for your application, along with scheduling your medical exam within 3–5 business days, to keep your policy approval moving quickly.

Important Notice: Your privacy is our priority. Your personal and health information is collected and stored through a compliant secure system. We do not sell your data, and it is only shared with authorized insurance carriers as required for underwriting and policy issuance. Submitting this application does not guarantee approval.

No payments will be processed without your review and consent to your agent.

Form Type *

Within the next 5 days, what morning works best for your quick, no-cost medical exam at home? (Please fast for at least 8 hours before.) *

Adult Information

First Name *

Last Name *

Gender *

Email *

Phone *

Date of birth (m/d/yyyy) *

Social Security Number *

US Residency Visa Status *

Please upload a clear picture of the Visa or Work Permit

IPA Owner Visa Work Permit File Upload

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF “Don’t have this right now? No worries — you’ll receive a link by email to upload it later.”

Height *

Weight *

Country of Birth *

State of Birth *

Address *

Years at Address *

Marital Status *

Annual Income *

Household Income *

Employment Status

Employment Status *

Employer Name *

Employer Address *

Type of Business *

How long have you been employed *

Position *

Annual Income *

Type of Business *

How long have you been self-employed? *

How long have you been unemployed? *

How long have you been retired? *

Beneficiary Information

Primary Beneficiary Full Name *

Primary Beneficiary Relationship to Policy Owner *

Primary Beneficiary Date of Birth (m/d/yyyy) *

Primary Beneficiary SSN

Primary Beneficiary Percentage *

Secondary Beneficiary Full Name *

Secondary Beneficiary Relationship to Policy Owner *

Secondary Beneficiary Date of Birth (m/d/yyyy) *

Secondary Beneficiary SSN

Secondary Beneficiary Percentage *

Contingent Beneficiary

Contingent Beneficiary #1 (If Primary Beneficiary passed away before the Contingent Beneficiary) *

Add

Don't Add

Contingent Beneficiary #1 Full Name *

Contingent Beneficiary 1# Relationship to Policy Owner *

Contingent Beneficiary #1 Date of Birth (m/d/yyyy) *

Contingent Beneficiary #1 SSN

Contingent Beneficiary #1 Percentage *

Contingent Beneficiary #2 (If Primary Beneficiary passed away before the Contingent Beneficiary) *

Add

Don't Add

Contingent Beneficiary #2 Full Name *

Contingent Beneficiary #2 Relationship to Policy Owner *

Contingent Beneficiary #2 Date of Birth (m/d/yyyy) *

Contingent Beneficiary #2 SSN

Contingent Beneficiary #2 Percentage *

Medical History

Primary Dr. Name / Practice Name / Urgent Care *

Primary Dr. Phone Number

Primary Doctor's Address

Date of Last Visit (m/d/yyyy) *

Reasons and Results of Last Visit *

Has the Insured ever been diagnosed or treated for any major or minor medical issues? *

Yes

Explain and provide Medical Conditions/Medications (Doctor's Information) *

Does the Insured take any medications regularly, including over-the-counter medications? *

Yes

Please specify the type of medications *

Family Medical History

Mother's Living Status *

Living

Deceased

Age *

Age at Death *

Cause of Death *

Father's Living Status *

Living

Deceased

Age *

Age at Death *

Cause of Death *

Siblings Information

How many siblings do you have? *

For each sibling, please provide: 1 - Gender, 2 - Living Status (Living or Deceased), 3 - Current Age (if Living), 4 - Age at Death (if Deceased), and 5 - Cause of Death (if Deceased)

Existing Insurance Policy

Does the Insured currently have any active life insurance policies? *

Yes

Name of Insurance Company *

Policy Type *

Policy Number

Coverage Amount *

Year Issued *

Bank Account

FInancial Institution Name (Bank Name)

Bank Account Number

Bank Routing Number

Other Information

Any Felonies, Misdemeanors or DUI's? *

Yes

Please specify *

How long ago did they occur? *

Are you currently on probation or parole? *

Yes

Please Specify *

Have you ever used tobacco or nicotine products in any form (including cigarettes, cigars, cigarillos, pipe, chewing tobacco, snuff, nicotine patches, nicotine gum, hookah)? *

Yes

Provide details below (product, frequency, date first use, date of last use) *

Do you drink alcohol? *

Yes

How often do you drink? *

Do you have airline tickets purchased to leave the United States in the next 12 months? *

Yes

Where? *

When? *

Please share any information you think we should be aware of *

Driver License Number *

Driver License Expiry Date (m/d/yyyy) *

Please Upload a clear copy of your Driver License, Passport or A Government Identification

Owner Driver License Passport ID File Upload

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF “Don’t have this right now? No worries — you’ll receive a link by email to upload it later.”

Client's Consent *

By signing below, I acknowledge that I have reviewed all information contained in this application. I confirm that the information provided is true, complete, and accurate to the best of my knowledge.

I am aware that providing false information may result in claim denial or policy cancellation.

Signature *

Clear