Baystate Brokers - Life Insurance Application

At Baystate Brokers, we believe that applying for life insurance should be easy.

Since Baystate Brokers, LLC works with multiple insurance companies, we are providing you with an online form to enter the majority of the information required to complete an application. However, this form is not an acutal application. Upon agreement between the applicant and Baystate Brokers, LLC regarding the amount of coverage being applied for, the insurance company and the premium, an official application will then be populated using the information provided below. Once complete, the application will be sent to the applicant/proposed insured via the United States Postal Service for signature and returned in a postage paid return envelope for further processing. In the event any required data was omitted or missing from the application, it will be noted on the paperwork for the applicant to populate manually.

Your privacy and the the security of your data is important to us. BaystateBrokers.com is a secure website to help ensure your privacy and personal information is protected. All data is transmitted in an encrypted manner and you can rest assured that your information will be kept confidential. We only share information with our insurance partners who assist us in determining rating class or are sent an official application for processing. All data is handled and stored in compliance with state and FINRA requirements.

If the web address at the top of the page does not begin with HTTPS://, please do not enter any data. If you prefer to provide your information over the telephone, please contact us to request a meeting.

Quote Number

Contained in your Baystate Brokers quote

Applicant

* Name (first, middle and last ):

Gender

Male

Female

Date of Birth

Are you a US citizen?

Yes

If no:

Visa Type:

Visa Duration:

Marital Status

Home Street Address:

City:

State:

Zip Code:

How long at this address?:

If less than 2 years at this address, please provide previous address:

Address:

City:

State:

Zip Code:

* E-mail:

Home Phone:

License Number:

State of Issue:

Expiration Date:

If additional information is needed, what is the best time and number to contact you?

Employment Information

Name of Employer:
Address:
City:
State:
Zip Code:
If address is a P. O. Box, please include street address.
Address:
City:
State:
Zip Code:

Business Phone:
Occupation:
Job Title:
Nature of Business:
How many years at this job?
Please provide previous employment information if at current employer for less than 2 years.
Name of Employer:
Address:
City:
State:
Zip Code:
Occupation:
Job Title:
Nature of Business:

Only complete if proposed insured is NOT the policy owner

Name (first, middle and last ):

Social Security Number or Federal Tax ID

Relationship to insured:

Same address as applicant?

Yes

Home Street Address:

City:

State:

Zip Code:

Telephone Number:

If the policy is owned by a Trust

Date of Trust

Complete names of authorized trustees:

Primary Beneficiary

Enter details for multiple beneficiaries below. Please verify that allocation is correct and totals 100%.

Name:

Relationship to insured:

Percentage:

Same address as applicant?

Yes

Street Address:

City:

State:

Zip Code:

Additional Primary Beneficiaries:

Contingent Beneficiary

Enter details for multiple beneficiaries below. Please verify that allocation is correct and totals 100%.

Name:

Relationship to insured:

Percentage:

Same address as applicant?

Yes

Street Address:

City:

State:

Zip Code:

Additional Contingent Beneficiaries:

Policy Information

Purpose of Insurance:

Please check all that apply.

Buy-Sell	Retirement
Deferred Compensation	Spouse/Child Insurance
Charitable Planning	Executive Bonus
Family Income	Collateral for Debt
Mortgage	Wealth Accumulation
Key Person	Education
Split Dollar	Other
Estate Planning

Gross Annual Income of Proposed Insured:

Household Income:

Net Worth:

Within the last 5 years, have you filed for bankruptcy or had any judgements or liens filed against you?:

Yes

If yes

Date of discharge:

Proposed Insured Personal History

* Provide additional details below for any Yes answer.

Have you ever sold a policy or been involved in any discussions about the possible sale or assignment of this policy to a life settlement, viatical or other secondar market Provider/Producer?

Yes

Do you have any other applications or informal inquiries for life insurance pending with any other company, society or association in the last 12 months?

Yes

Have you ever had an application or reinstatement request for life or disability insurance refused, postponed, limited, withdrawn, or cancelled, or have you been asked to pay a higher premium?

Yes

Have you, in the last 3 years, resided or traveled, or do you intend to reside or travel, outside of the United States?

Yes

In the last 3 years, has your driver's license been suspended or revoked, or have you received any moving violations?

Yes

Have you ever been convicted of reckless driving, driving to endanger or driving under the influence of drugs or alcohol?

Yes

Except for traffic violations, have you been the subject of, or been convicted of, a misdemeanor or felony, or are you awaiting trial for a felony?

Yes

Have you in the last 3 years engaged in, or do you intend to engage in, flying a plane, racing motor boats or motor vehicles, or participate in sky-diving or parachuting, hang-gliding, hot air ballooning, mountain, rock or ice climbing, scuba diving or other hazardous activities?

Yes

Are you currently or intend to become a member of the Armed Forces, including
the Reserves or National Guard?

Yes

Please provide additional details for all Yes answers:

Policy Information

Method of initial payment:
if other:
Payment mode:
Send premium notices to :
If you intend to replace existing coverage, please tell the Producer of your intention and answer "Yes" to replacement question #2 below. State law may require the Producer to give you information that will help you compare the policy you are applying for with the policy you intend to replace. If you are undecided about keeping existing coverage, indicating an intention to replace existing coverage may help you get the information you need to make a decision. If you do replace existing coverage, the new policy may contain, among other things, new suicide exclusions and contestability periods. Ask the Producer if you are unsure.

Proposed Insured Owner

1. Do you have an existing or pending life insurance policy or annuity contract?

Yes

2. Do you intend to replace any existing life insurance or annuity contract?

Yes

3. Are you considering using funds from an existing policy or contract to pay premiums on the policy you are applying for?

Yes

4. Have you stopped making premium payments, surrendered, forfeited, assigned to the Company, or otherwise terminated an existing policy or contract or are you considering doing so? (If Yes, complete state require replacement form and provide details below)

Yes

Enter each contract/policy on a separate line. Do not include group policies.

Company

To be replaced?

Policy #

Cash Value

Date of Issue

Yes

Proposed Insured Medical History

Name, address and phone number of your primary care physician (if no PCP, provide names,
addresses and phone numbers of care providers last seen, dates and the reasons for the visits. If
none, state "NONE").

For the past 5 years, describe dates, reasons consulted, and any treatments or medications
prescribed.

Height: Weight:

Have you had any weight change in excess of 10 pounds within the past year?

Yes

Have you ever had, been treated for, or been medically advised to be treated for the following? Please provide details for any Yes answers.

Anemia or other blood disorder

Yes

High Blood Pressure

Yes

Angina/Chest Pain

Yes

Kidney Disorder

Yes

Anxiety/depression/mental disorder

Yes

Lupus (SLE)/Scleroderma

Yes

Asthma

Yes

Lymph Gland Disorder

Yes

Backache or Sciatica

Yes

Multiple Sclerosis

Yes

Bone, Joint or Arthritis

Yes

Palpitations/Arrhythmia

Yes

Bronchitis

Yes

Pancreatitis or other disorder of the pancreas

Yes

Cancer

Yes

Paralysis

Yes

Chronic Headaches

Yes

Pituitary Disorder

Yes

Circulatory Disorder

Yes

Prostate Disorder

Yes

Clotting Disorder

Yes

Respiratory Disorder/Chronic Cough

Yes

Colitis/Ileitis

Yes

Spitting up Blood

Yes

Disease of the brain or nervous system

Yes

Any Sexually Transmitted Disease

Yes

Disease of the liver or gallbladder

Yes

Shortness of Breath

Yes

Dizziness/Fainting

Yes

Skin Disorder

Yes

Emphysema

Yes

Sleep Apnea

Yes

Epilepsy/Seizures

Yes

Stroke

Yes

Gastrointestinal/Esophageal Disorder/Ulcer

Yes

Sugar/Protein or Blood in Urine

Yes

Genito-Urinary Disorder

Yes

Suicide Attempt

Yes

Heart Attack/Heart Disease

Yes

Thyroid Disorder

Yes

Heart Murmur/Rheumatic Fever

Yes

Tuberculosis

Yes

Hepatitis

Yes

Tumor, Mass or Lump

Yes

Please provide details for any Yes answer:

In the past 5 years have you:

Consulted with or received treatment from a care provider or treatment facility?

Yes

Had an EKG, X-RAY, or other diagnostic test, other than AIDS-related test?

Yes

Been advised to have any diagnostic test, other than AIDS-related test, hospitalization or surgery that was not completed?

Yes

Had medication prescribed for any other condition not listed above?

Yes

Ever received or claimed disability or hospital indemnity benefits or pension for any injury, sickness, disability or impaired condition?

Yes

Sought or received advice, counseling or treatment by a care provider for the use of alcohol or drugs, including prescription drugs?

Yes

Used cocaine, marijuana, heroin, narcotic, stimulants, sedatives, hallucinogens, controlled substance or any other drug, except as legally prescribed by a physician?

Yes

Been diagnosed as having or been treated by a care provider for AIDS Related Complex (ARC) or Acquired Immune Deficiency Syndrome (AIDS)?

Yes

Used alcoholic beverages?

Yes

If yes, Type:

Frequency:

Amount:

Do you have symptoms or knowledge of any other conditions that are not disclosed above?

Yes

Please provide details for any Yes answer.

Family History

If additional space is needed for family members or family history, please enter details below.

Relative

Age if living

State of Health

Age of Death

Cause of Death

History of diabetes, cancer, heart disease or cardiovascular disease?

Mother

Yes

Age of onset:

Diabetes

Cancer

Heart Disease

Cardiovascular Disease

Other:

Father

Yes

Age of onset:

Diabetes

Cancer

Heart Disease

Cardiovascular Disease

Other:

Yes

Age of onset:

Diabetes

Cancer

Heart Disease

Cardiovascular Disease

Other:

Yes

Age of onset:

Diabetes

Cancer

Heart Disease

Cardiovascular Disease

Other:

Yes

Age of onset:

Diabetes

Cancer

Heart Disease

Cardiovascular Disease

Other:

Yes

Age of onset:

Diabetes

Cancer

Heart Disease

Cardiovascular Disease

Other:

Yes

Age of onset:

Diabetes

Cancer

Heart Disease

Cardiovascular Disease

Other:

Additional family details:

Is there any other information that you need to share?

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