Let's get your application started.
Take your time — there are no wrong answers. We'll go through it one section at a time so it's easy to follow. All information is kept private and secure.
About You — the Policy Owner
Your personal and contact information
About the Person Who Is Insured
The person whose life is covered by the policy
Your Doctors & Medical Specialists
All practitioners who have treated you in the past 5 years
Please list all doctors, specialists, or clinics from the past 5 years. If any are affiliated with a hospital, medical group, or the VA, let us know — we'll reach out about an additional form. Call (888) 358-7878 with questions.
Beneficiaries
Who is currently named on your policy to receive the benefit
A beneficiary is the person who would receive the policy payout. Just name and relationship is fine — list up to three.
A Few Policy Questions
Simple yes/no questions about your insurance history
Any Debts or Claims on the Policy?
Most people can skip this — only fill it in if someone has a legal claim against your policy
A lien means a lender, court, or creditor has a legal claim against your policy. Most people have none. If unsure, leave this blank and our team will check with you.
| Describe the debt or claim | Name of creditor / lienholder | Amount ($) |
|---|---|---|
Required Authorizations — What Happens Next
No action needed here — we'll send both forms to you personally after submission
After you submit, we'll send you two forms that require a physical (pen & ink) signature. Both must be returned to us before we can move your case forward. Digital or electronic signatures are not accepted for either document.
Form 1 — HIPAA Release of Health Information
HIPAA is a federal law that protects your medical records. This form gives us written permission to request your medical records from your doctors and hospitals so we can properly evaluate your case.
We send you the HIPAA Release of Health Information form by email or mail.
You sign it by hand and return it to us.
Our team uses it to request your medical records from your healthcare providers.
Form 2 — Release of Policy Information
This form gives us permission to contact your insurance company directly and request your policy documents — including your policy copy, annual statements, premium details, and in-force illustrations.
We send you the Release of Policy Information form by email or mail.
You sign it and fill in your insurance company name, policy number, and name as insured.
We contact your insurance company on your behalf to collect all necessary documents.
Ready to submit?
Once submitted, a specialist will review your information and contact you within 24 hours. You'll also receive the HIPAA form by email shortly after.
Application Received!
Thank you, . Your application has been submitted. Our team will review it and reach out within 24 hours. We'll also send your HIPAA form shortly.