EALTHSure LIFETM - .SECTION B – OWNER (IF OTHER ... assignment of this Policy or a beneficial interest

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    Interest Sensitive Single Premium Whole Life Insurance

    Client Information Name


    Street Address


    Agent Information Name



    Pre-Qualification: Review list of impairments in the WealthSure Life Agent Guide with your client. If the client acknowledges having any of the listed diseases or conditions, the client is not a candidate for the WealthSure Life product. For alternative product ideas, call EquiTrust Sales Support at 800-811-9733. Illustrations: Return signed copy and Illustration Acknowledgement form with the application. Telephone Underwriting Interview: Mid-America Agency Services (MAAS)/Hooper Holmes will facilitate the interview on behalf of EquiTrust Life. The interview will take 2025 minutes. Point-of-sale interview: Call MAAS/Hooper Holmes at 800-577-5844 during regular business hours: Mon Thurs 8 AM 9 PM CST or Friday 8 AM 5 PM CST. A few questions will be directed to you and all other questions directed to your client. Interview at a later date: Please provide the information below. MAAS/Hooper Holmes will attempt to contact your client at the designated time. You need not be present for interviews scheduled at a later date. Interview preparation: Your client should have available the names and addresses for all physicians; dates of physician and facility visits; current medications and dosages; details of injuries, conditions and illnesses; and their Social Security number. Application: Fax the completed application and this form to EquiTrust at 515-226-5103. The underwriting process will not begin until the application and this form are received. You will be notified by email of approval/decline. You may also check on the website at the Pending Business link. Mail all appropriate forms and the premium check (or transfer form) to EquiTrust: Standard: EquiTrust Life Insurance Company, PO Box 14500, Des Moines, IA 50306-3500 Overnight: EquiTrust Life Insurance Company, 7100 Westown Pkwy Suite 200, West Des Moines, IA 50266-2521

    Telephone Interview Choose One: My client has completed the telephone interview with MAAS/Hooper Holmes. The interview was completed:


    My client wishes to be called by MAAS/Hooper Holmes. Best time of day for MAAS/Hooper Holmes to call:

    Time: AM/PM Time Zone:

    ETL-WSL-SELLGUIDE (1-14)SALES SUPPOrT: 800-811-9733 Email: LifeSales.Support@EquiTrust.com

  • Page 1 of 9

    Policy #

    (Home Office Use Only)

    Producer Name Full Office Address Office Phone # Producer # % #1


    All references to "the Company" shall mean EquiTrust Life Insurance Company of West Des Moines, Iowa, 50266. SECTION A PROPOSED INSURED AND BENEFICIARY INFORMATION Complete Name of Insured (first-middle-last)



    Birth Date Birth State Social Security Number Height Weight

    Residential Address City State ZIP

    Telephone (Day and Evening) Email Address

    Primary Beneficiary(ies) (attach separate list if needed) SSN/TIN Relationship to Proposed Insured

    Contingent Beneficiary(ies) (attach separate list if needed) SSN/TIN Relationship to Proposed Insured

    Check here if you are attaching additional Beneficiary information. Check here if the trust will be an owner of the Policy, and also complete the Trust Information Form, ET-TRUST-2502.

    SECTION B OWNER (IF OTHER THAN PROPOSED INSURED) (IF LEFT BLANK, OWNER WILL BE THE SAME AS THE INSURED) Complete Name of Owner (first-middle-last) Birth Date Social Security Number Relationship to Proposed

    Insured Telephone (Day and Evening) Email Address

    Residential Address City State ZIP

    Complete Name of Contingent Owner (if any) - (first-middle-last) Relationship of any Contingent Owner to Proposed Insured


    Product Premium Amount $ SECTION D PERSONAL HISTORY QUESTIONS 1. Have you ever had life or health insurance declined, non-renewed, rated, modified, postponed or

    cancelled? Yes No

    2. Have you used any form of tobacco or nicotine-based products in the last 24 months? Yes No 3. Within the past 2 years have you: a. Flown or do you intend to fly as a pilot or crew member of any aircraft? b. Engaged in sky diving, hang gliding, scuba or skin diving, vehicle racing, mountain or rock climbing or rodeo activities?

    Yes No

    Yes No

    4. Within the past 10 years have you: a. Used illegal drugs, been treated or advised to have treatment for alcohol or drug use,

    (including prescription drugs)? b. Been convicted of or awaiting trial for a felony or are you currently on probation or parole?

    Yes No

    Yes No

    5. Within the past 5 years have you had a DUI/DWI? Yes No

    6. Within the past 3 years have you had more than one motor vehicle accident or moving violation? Yes No 7. Do you anticipate residence or travel for more than 3 months outside the United States, Canada or

    Mexico during the next 12 months? Yes No

    8. Are you a citizen of the United States? Yes No

    EquiTrust Life Insurance Company 7100 Westown Pkwy Suite 200 West Des Moines IA 50266-2521



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    SECTION E HEALTH QUESTIONS 1. Has any person proposed for coverage been treated, diagnosed, or given medical advice by

    a member of the medical profession for:

    a. Uncontrolled high blood pressure, chest pain, heart attack or failure, irregular heart rhythm, heart surgery, stroke or any other disease or disorder of the heart or blood vessels?

    Yes No

    b. Cancer, melanoma, leukemia or had more than one occurrence of cancer in your lifetime (excluding basal or squamous cell skin cancer)?

    Yes No

    c. Diabetes, hepatitis, organ transplant, unexplained weight loss over 10 pounds, any disease or disorder of the liver, kidney (including dialysis) or digestive system?

    Yes No

    d. Emphysema or any other chronic lung or respiratory disorder? Yes No e. Epilepsy, seizures, Alzheimers Disease, dementia, memory loss, mental or nervous disorder,

    including depression or anxiety? Yes No

    f. High cholesterol? Yes No g. Anemia or any other disease or disorder of the blood or immune system (excluding HIV/AIDS)? Yes No h. Any disease or disorder of the muscles, bones or joints? Yes No i. Any other disease or disorder not listed above? Yes No

    2. Has any person proposed for coverage been diagnosed by a member of the medical profession or tested positive for the Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS)?

    Yes No 3. Within the past 12 months have you been or advised by a member of the medical

    profession: a. To be hospitalized, confined to a nursing home, hospice, convalescent, long term care,

    assisted living, or mental facility, or diagnosed with a terminal illness (life expectancy of 12 months or less)?

    b. To have or have scheduled a surgical operation, diagnostic test, or evaluation that has not yet been completed, except those tests related to the Human Immunodeficiency Virus (AIDS virus)?

    Yes No

    Yes No

    4. Are you currently under treatment or taking prescription medication? Yes No 5. Have you seen a doctor or other medical professional in the past 12 months? Yes No

    6. Within the past 5 years, have you been unable to perform or do you require supervision or assistance in performing the activities of daily living dressing, eating, ambulating, toileting, transferring or bathing?

    Yes No

    Provide details of all Yes answers from Sections D and E in the area below (Use comments section if additional space is needed.) Question # Explanation Dates/Duration Name of Medical Professional


    (Attach a separate sheet if more space is needed.)


  • Page 3 of 9

    SECTION G EXISTING COVERAGE/REPLACEMENT 1. Does either the Owner or Proposed Insured have any other life insurance policies or

    annuity contracts? If "Yes" and required by your state, complete the Replacement Notice.

    Yes No

    2. Is the Policy applied for replacing or likely to replace any existing life insurance or annuity contracts? If "Yes," complete any required Replacement Notice.

    Yes No

    3. Are values from an existing life insurance policy or annuity being used to pay

    premiums on the new Policy? If "Yes" and required by your state, complete the Replacement Notice.

    Yes No

    SECTION H ADDITIONAL QUESTIONS Details to each Yes answer 1. Will the Proposed Owner and/or Beneficiary,

    and/or any entity on the Proposed Owners behalf, receive any compensation, whether via the form of cash, property, an agreement to pay money in the future, a percentage of the death benefit, or otherwise if this Policy is issued?

    Yes No

    2. Has the Proposed Owner been involved in any discussion about the possible sale or assignment of this Policy or a beneficial interest in a trust, LLC, or other entity created on the Owners behalf?

    Yes No If yes, provide details and a copy of the applicable entitys controlling documents.

    3. Is this Policy being funded via a premium financing loan or with funds borrowed, advanced or paid from another person or entity?


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