URLThis field is for validation purposes and should be left unchanged.Applicant InformationApplicant Entity Type(Required) Individual Partnership Corporation LLC Joint Venture Other Applicant Name:(Required)Applicant’s Full Name(Required) First Last Applicant's Company Name:(Required)(N/A if you don't have one)Owner’s Full Name(Required) First Last Business Address(Required) Street Address Address Line 2 City State ZIP / Postal Code Is business address different than mailing address?(Required) Yes No Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number(Required)FaxEmail(Required) Website Does the applicant have a DBA (Doing Business As) name:In what year did the applicant start operations?(Required)2026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900Please describe the applicant's day-to-day business operations: (Please be detailed)(Required)Are there any locations or business interests that are owned by the applicant but not shown on the application?(Required) Yes No Are there high-valued goods, including merchandise at your location?(Required) Yes No If yes, what is the approximate value of your inventory?Please enter a number greater than or equal to 0.What is the value of your business personal property? (BPP are all your furniture, computers, printers, etc. Basically, anything you will take with you if you move)(Required)Please enter a number greater than or equal to 0.Employee & Eligibility InformationTotal Number of EmployeesFull-Time Employees:(Required)Please enter a number greater than or equal to 0.Part-Time Employees:(Required)Please enter a number greater than or equal to 0.Seasonal/Temporary Employees:(Required)Please enter a number greater than or equal to 0.How many employees are eligible for life insurance coverage?(Required)Please enter a number greater than or equal to 0.How many employees are currently enrolled in a life insurance plan?(Required)Please enter a number greater than or equal to 0.Do you wish to provide coverage for:(Required) Employees Only Employees & Dependents Employees, Dependents, & Spouse Do you have a waiting period for new employees?(Required) Yes No If yes, how long?(Required) 30 days 60 days 90 days Other Coverage & BenefitsType of Group Life Insurance Requested: Basic Group Life Insurance Voluntary/Optional Life Insurance Accidental Death & Dismemberment (AD&D) Coverage Dependent Life Insurance Coverage Key Person Life Insurance Requested Coverage Amount per Employee: Flat Amount (e.g., $25,000 per employee) Salary-Based (e.g., 1x or 2x annual salary) Tiered Benefits Tiered Benefits (please specify):(Required)Employer Contribution Toward Premiums:(Required) 100% Employer-Paid 75% Employer-Paid 50% Employer-Paid Other Do employees have the option to purchase additional life insurance?(Required) Yes No Would you like to include: Waiver of Premium for Disability Accelerated Death Benefits Conversion Option (to individual policy upon employment termination) Employee Demographics & CensusPlease provide a census of employees, including: (Attach spreadsheet if available)(Required)Employee Name (or ID)Date of BirthGenderJob TitleWork Location (State)Employment Status (Full-Time/Part-Time)Current Life Insurance Coverage (if applicable) Add RemoveYou may also upload a document rather than enter information for each employee above.Document must have all of the following information for each employee: (Name, DOB, Gender, Job Title, Work Location, Employment Status (Full-time, Part-time, Etc), Current Life Insurance Coverage status/info) I want to upload a document instead Employee Information - Document Upload(Required)Max. file size: 50 MB. Are there any retirees or former employees needing continuation coverage?(Required) Yes No Are there any high-risk occupations among your employees (e.g., construction, manufacturing, hazardous material handling)?(Required) Yes No If yes, please specify:(Required)Insurance History & Claims InformationDo you currently have group life insurance coverage?(Required) Yes No If yes, name of current insurer:(Required)Policy expiration date:(Required) MM slash DD slash YYYY Have you experienced any significant rate increases in the past three years?(Required) Yes No If yes, please provide details:(Required)Have you had any life insurance claims in the past five years?(Required) Yes No If yes, please provide details:(Required)Has the applicant ever had life insurance coverage canceled or non-renewed?(Required) Yes No If yes, please provide details:(Required)Additional Comments or Special ConsiderationsPlease provide any other relevant information that may impact your insurance coverage needs. 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