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

Juvenile Information

Together, We Protect What Matters Most

Our case managers will contact the policy owner within the next 48 hours to help collect any required medical records for the child’s application, ensuring the policy approval process continues smoothly.

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 *

Juvenile
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Agent Name

Agent Email

Owner of Juvenile Policy

First Name *

Last Name *

Gender *

Male
Female
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Email *

Phone *

Date of birth (m/d/yyyy) *

Social Security Number *

US Residency Visa Status *

U.S. Citizen
U.S. Permanent Resident (Green Card holder)
Lawful Resident Alien (with visa)
Non-Resident Alien
Visa or Work Permit Holder
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List is empty.

Please upload a clear picture of the Visa or Work Permit

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.”

What is your relationship to the proposed insured (Juvenile)? *

Parent
Grandparent
Legal Guardian
Sibling
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Juvenile Information

First Name *

Last Name *

Gender *

Male

Female

Date of Birth (m/d/yyyy) *

Height *

Weight *

Social Security Number *

US Residency Visa Status *

U.S. CitizenU.S. Citizen
U.S. Permanent Resident (Green Card holder)
Lawful Resident Alien (with visa)
Non-Resident Alien
Visa or Work Permit Holder
No elements found. Consider changing the search query.
List is empty.

Please upload a clear picture of the Visa or Work Permit

Insured 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.”

Country of Birth *

Address *

Street Address

City

State

Country

Postal Code

Years at Address *

Marital Status *

Single
Married
Divorced
Widowed
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Owner’s Employment Status

Employment Status *

Employed (full-time or part-time)
Self-Employed
Unemployed
Retired
Homemaker
Student
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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 *

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 *

Juvenile 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 *

Juvenile's 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 *

Juvenile's Siblings

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 *

Term
Whole Life
Universal Life
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Policy Number

Coverage Amount *

Year Issued *

Bank Account

Financial Institution Name (Bank Name)

Bank Account Number

Bank Routing Number

Other Information

Owner's Driver License Number *

Owner's Driver License Expiry Date (m/d/yyyy) *

Please Upload a clear copy of the Owner's 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.

Owner's Signature *

Clear