Life Insurance Application

Complete this comprehensive application for individual life, final expense, and wealth-transfer coverage. Provide full details about your personal information, financial situation, health history, and beneficiaries to help us quote the best coverage for you.

Return the completed form by email to service@archerinsgroup.com. Questions? Call 281-501-8331.

Works on any phone, tablet, or computer — no app needed. Type N/A where a field does not apply. Fields marked * are required.

Proposed Insured — Personal Information

Date Needed / Due

Desired Effective Date

How Did You Hear About Us?

Referred By (name)

Proposed Insured — Full Legal Name *

Date of Birth

Gender

Mailing / Residential Address

Apt / Unit

City

State

ZIP

County

Time at Address

Marital Status

Phone Number

Best Time to Call

Can We Text You?

Email *

Country of Birth

State of Birth

Type of Citizenship

Height & Weight

Driver's License No.

DL State

SSN (optional)

Occupation / Profession

U.S. Ties & Assets

Do you own a home in the U.S.?

If yes, property address

Do you own a business in the U.S.?

Type of Business

Business Address

Do you own other U.S. assets — stocks, bonds, savings, securities, or real estate?

Policy Owner complete only if the owner is not the proposed insured

Is the policy owner the same as the proposed insured?

Owner — Full Legal Name

Relationship to Insured

Date of Birth

SSN / FEIN

Owner Address

Phone

Coverage Requested check all that apply

Term Life Whole Life Universal Life (UL)

Indexed Universal Life (IUL) Guaranteed / Final Expense Group / Voluntary Life

Key-Person / Buy-Sell Survivorship / Second-to-Die Annuity / Wealth Transfer

Not sure — recommend for me

Face Amount Requested $

Requested Term / Duration

Target Premium (monthly $)

Payment Mode

Do you have a set budget you do not want to exceed?

Maximum Budget $ (not to exceed)

Budget Basis

Advanced / High-Net-Worth Tax Planning optional

For high-net-worth clients, permanent life insurance can minimize income and estate taxes: tax-deferred cash-value growth, tax-free policy loans for retirement income, and a death benefit that passes income-tax-free and, when owned in an ILIT, outside the taxable estate. Ask us about premium-financed policies and defined benefit / cash-balance plan funding. J. Archer Insurance Group coordinates with your CPA and attorney and does not provide tax or legal advice.

Estate-tax liquidity / transfer Trust-owned / ILIT Premium-financed policy

Tax-deferred cash value Tax-free income via policy loans Defined benefit / cash-balance

Executive benefits / split-dollar Not sure — recommend a strategy

Purpose of Coverage / Riders Requested (e.g., income replacement, mortgage, estate, waiver of premium, ADB, child rider)

Existing Life Insurance

Total Life Insurance In Force $

Is this a conversion or insurability option?

Will this replace existing coverage?

List current carriers and amounts

Carrier 1

Amount $

Carrier 2

Amount $

Personal History & Lifestyle

Is the proposed insured currently disabled or applying for any disability benefits?

Used tobacco / nicotine products in the last 12–24 months?

Cigars used in the last 24 months? (number per year)

Used Rx smoking-cessation aids in last 12 months?

Convicted of a felony, or currently on parole / probation?

Convicted of DUI / DWI in the last 5 years?

At-fault motor vehicle accident in the last 3 years?

Anticipated foreign travel in the next 2 years?

Travel or Reside?

Locations of past & future travel

Are you currently, or planning to become, a member of the Armed Forces?

Do you expect to become a pilot or crew member in the next 2 years?

Do you participate in high-risk activities (skydiving, racing, scuba, aviation, etc.)?

Provide details for any "Yes" answers above

Employment & Financial

Current Occupation

Exact Duties

Employer / Business Name

Employer Address

Earned Income — Current Yr $

Earned Income — Prior Yr $

Household Net Worth $

Unearned Income — Current Yr $

Unearned Income — Prior Yr $

Primary Physician

Physician Name

Phone

Date / Timeframe Last Seen

Physician Address

Reason / Details of Last Visit

Current Medications (name, dose, reason)

Medical History past 10 years — diagnosed, treated, or tested positive

Heart disease or high blood pressure

Kidney, liver, or digestive-system disorder

Cancer, tumors, or leukemia

HIV / AIDS

Stroke, seizures, or neurological disorder

Non-prescribed controlled substances (last 10 yrs)

Depression, anxiety, or mental-health condition

Treatment / counseling for alcohol or drug abuse

Diabetes, thyroid, or gland disorder

Details for any "Yes" above (condition, date, treatment, current status)

Family Health History immediate family: father, mother, siblings

Family Health History Table

For each family member, provide: Name, Living? (Y/N), Current Age / Age at Death, Major Diagnosis / Condition, Age at Onset

Family Member 1: Name

Living? (Y/N)

Age

Diagnosis / Condition

Age at Onset

Family Member 2: Name

Living? (Y/N)

Age

Diagnosis / Condition

Age at Onset

Family Member 3: Name

Living? (Y/N)

Age

Diagnosis / Condition

Age at Onset

Family history of heart disease or cancer?

Any inherited / genetic conditions?

If yes, describe

Beneficiaries

Primary Beneficiary

Full Name

Relationship

Date of Birth

Distribution %

SSN

Phone

Address

Contingent Beneficiary

Full Name

Relationship

Distribution %

If a Beneficiary is a Minor — Custodial Information

Custodian Name

Relationship

Who will own the policy if the owner passes?

Authorization & Sign-Off

Authorization & Broker of Record / Exclusive Representation Acknowledgment *
I authorize J. Archer Insurance Group to obtain information needed to market my coverage and to act as my exclusive broker for this submission. I certify the above is true and complete. Duplicate submissions by other agents can delay or jeopardize the best pricing.

Applicant Signature (type full name) *

Date *

Print Name & Title

Policy Owner Signature (if different)

Tap Submit to send your answers to our team, or Save / Print as PDF to keep a copy and email it to service@archerinsgroup.com. Questions? Call 281-501-8331.

What Happens Next

Your application will be reviewed by our dedicated Life & Wealth Planning team, who will guide you through underwriting and help you secure the right coverage for your family's legacy and financial goals. We coordinate with your trusted advisors to ensure comprehensive protection.