[Breathe – Life Insurance Logn Form]

Type of Policy*
Term*
Amount of insurance applying for*
Please enter a number from 50000 to 3000000.
General Health
Height
Weight
Do you use Tobacco?
Do you smoke Cigars?*
Please indicate your cigar usage in the past 12 months*
List any prescriptions, dosage, and usage (how often) that you take
Personal Information

Do you have any life insurance or annuities currently in force or pending?*
- No
- Yes
Company Name*
Will this policy be replaced or changed?*
Year Issued*
Basic Amount*
Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract?*
- No
- Yes
The existing policy or contract is being replaced because:*
Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy?*
- No
- Yes
HIV Consent
In the event of a positive HIV test result, send the result to:*
- Don't notify anybody but myself
- Personal Physician
- Health Care Provider
Physician Name*
First Last
Physician Address*
Street Address City State Zip Code
Health Care Provider Name*
Health Care Provider Address*
Street Address City State Zip Code
Premium Information

Have or will you receive any compensation, including, but not limited to cash or property in connection with the issuance of this or any other policy?*
- No
- Yes
Provide Details*
Have you been involved in any discussion about selling, transferring, or assigning this policy or any rights under it? (Selling or assigning means the rights of the life insurance policy are transferred to another party)*
- No
- Yes
Provide Details*
Will funds from a qualified plan or IRA be used to pay all or a portion of the premiums for this policy?*
- No
- Yes
Preferred Payment Frequency*
Payment Type*
Source of Payment*

Your Information