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Fidelity Life’s Rapid Decision Universal Life insurance is designed to make the entire application and approval process with Fidelity Life Association easy for you. Fidelity Life’s Rapid Decision Universal Life product provides flexible premiums coupled with competitive cash value accumulation. It is an ideal product for those who seek solid life insurance protection, flexibility, and sustainable cash value accumulation. Coverage is available for people ages 16 to 75 years.  

Start the APPLICATION process now by answering the questions below. Your information will be transferred to the application which will be emailed to you for your final review and approval by e-signature.
For any Assistance please Call (800) 393-3592.
For your convenience we can do the application by phone. For assistance in finding a life insurance solution with other Carriers and plans please Call (800) 393-3592.
Applicants must be a U.S. Citizen or have permanent resident status (green card). Occasionally a medical exam, test or report will be ordered to assist in clarifying or correcting an item of medical history.

   
PROPOSED INSURED  
Full Legal Name of the Proposed Insured*: 
First | M. | Last
Gender *: 
Date of Birth *: 
/ /
Age: 
Place of Birth: 
Social Security Number: 
Legal Residence Address: 
Years at this Address: 
City*: 
State: 
Zip: 
Day Phone*: 
- -
Evening Phone: 
- -
Best Time to Call (If Needed): 
 - 
Email*: 
Are you a U.S. Citizen or do you have  Permanent  Resident Status (a Green Card)?: 
Driver's License Number: 
   State of Issue:    
Occupation: 
   Years in this occupation:
Employer or Business Name: 
   Annual Income:    
COVERAGE  
Choose A Product*: 
Face Amount*: 

 Issue Limits:Age 16-45,$50,000 to $300,000 | Age 46-55,$50,000 to $200,000
| Age 56-65,$25,000 to $100,000 | Age 66-75,$10,000 to $25,000
.

Coverage Length*: 
Dependent Child Rider: 
  Amount:
Accidental Death Rider: 
  Amount:
Waiver of Premium Rider: 
Billing Modes: 
   
OTHER COVERAGE
(Please list the following)
Do you have any existing life insurance in force or is any application for life insurance, or reinstatement, now pending?
1. Other Life Insurance - Name of Company, Face  Amount $ , Year Issued: 
   Replace:
2. Other Life Insurance - Name of Company, Face  Amount $ , Year Issued: 
   Replace:
3. Other Life Insurance - Name of Company, Face  Amount $ , Year Issued: 
   Replace:
4. Other Life Insurance - Name of Company, Face  Amount $ , Year Issued: 
   Replace:
If this policy is issued: 
Will any other existing life insurance or annuity be cancelled, terminated, lapsed or not renewed?
   
Owner and Beneficiary  
Policyowner (The Policyowner will be the Proposed  Insured unless otherwise indicated): 
 Policyowner
 (Not Proposed Insured):

 Relationship to Insured:
 SSN/TaxID:
Billing Address: 
Secondary Addressee (Optional - This person will  receive copies of your overdue premium and lapse  notices): 
 Name:
 Mailing Address:
   
Primary Beneficiary (Complex beneficiary  designatins should be dealt within the context of a  Will): 
1. Primary Beneficiary
 Full Name:
Percentage %: (1-100%)
 Relationship to Insured:   SSN/TaxID:
  2. Primary Beneficiary
 Full Name:
Percentage %: (1-100%)
 Relationship to Insured:   SSN/TaxID:
  3. Primary Beneficiary
 Full Name:
Percentage %: (1-100%)
 Relationship to Insured:   SSN/TaxID:
  4. Primary Beneficiary
 Full Name:
Percentage %: (1-100%)
 Relationship to Insured:   SSN/TaxID:
   
Contingent Beneficiary: 
1. Contingent Beneficiary
 Full Name:
Percentage %: (1-100%)
 Relationship to Insured:   SSN/TaxID:
  2. Contingent Beneficiary
 Full Name:
Percentage %: (1-100%)
 Relationship to Insured:   SSN/TaxID:
  3. Contingent Beneficiary
 Full Name:
Percentage %: (1-100%)
 Relationship to Insured:   SSN/TaxID:
  4. Contingent Beneficiary
 Full Name:
Percentage %: (1-100%)
 Relationship to Insured:   SSN/TaxID:
Applicant Questions  
1. Do you have a regular physician?: 
 1: If YES, give information below. If NO, show the last physician seen.
 Physician Name:
Date last seen:
 Physician Address:
 Physician Telephone: - -
2a. Your Height & Weight*: 
 2a: Height Feet -  Inches           Weight Lbs.
2b. Have you lost weight in the past year?:  
 2b:    If YES, give weight lost: Lbs.
 3a. Have you, within the past 10 years, been treated by a licensed member of the medical profession for or been diagnosed as having:
 3a. a heart disorder, including a heart attack (myocardial infarction),  angina, irregular heart beat or abnormal heart rhythm (arrhythmia),  heart murmur, any blockage or narrowing of the arteries, any aneurysm,  stroke, or transient ischemic attack (TIA or mini-stroke)?
 3a:
 3b. Have you, within the past 10 years, been treated by a licensed member of the medical profession for or been diagnosed as having:
 3b. diabetes, high blood sugar, sugar in the urine, anemia, blood or  platelet disorders, liver disease, kidney disease (other than kidney stones), Crohn’s disease, ulcerative colitis, other  intestinal disease or pancreatitis?
 3b:
 3c. Have you, within the past 10 years, been treated by a licensed member of the medical profession for or been diagnosed as having:
 3c.internal cancer or tumor, melanoma, lymphoma, leukemia,?
 3c:
 3d. Have you, within the past 10 years, been treated by a licensed member of the medical profession for or been diagnosed as having:
 3d. Alzheimer’s disease (dementia) , memory loss, seizures, mental  retardation (including Down’s syndrome), Multiple Sclerosis (MS),  Muscular Dystrophy, Parkinson’s disease, Amyotrophic Lateral Sclerosis  (ALS), cerebral palsy or any form of muscular atrophy?
 3d:
 3e. Have you, within the past 10 years, been treated by a licensed member of the medical profession for or been diagnosed as having:
 3e. sleep apnea, cystic fibrosis, emphysema or chronic obstructive lung  disease (COLD), rheumatoid arthritis, paralysis, connective tissue  disorder (lupus or scleroderma)?
 3e:
 3f. Have you, within the past 10 years, been treated by a licensed member of the medical profession for or been diagnosed as having:
 3f. Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related  Complex (ARC) or any other disorder of the
 Immune system?
 3f:
 3g. Have you, within the past 10 years, been treated by a licensed member of the medical profession for or been diagnosed as having:
 3g. enlarged prostate or elevated prostate specific antigen (PSA) or any  disorder of the breast?
 3g:
 3h. Have you, within the past 10 years, been treated by a licensed member of the medical profession for or been diagnosed as having:
 3h. hypertension (high blood pressure), elevated cholesterol, asthma or  other respiratory disorder?
 3h:
 3i. Have you, within the past 10 years, been treated by a licensed member of the medical profession for or been diagnosed as having:
 3i. anxiety, depression, eating disorders or any other psychological or  emotional disorders?
 3i:
4. Have you ever tested positive for Human Immunodeficiency Virus (HIV) antibodies as part of test for obtaining insurance?:    4:
5. Have you, within the past 12 months, received disability benefits of any kind or been disabled for more than 30 days?:
 5:
6.Other than as already disclosed above, are you currently taking any medication (by prescription or over the counter), or receiving medical or mental health treatment of any kind?:
 6:
7. Was the reason you last consulted your physician for any reason other than as already disclosed above?:
 7:
 8a. Have you, within the past 5 years: 
 8a. been a patient in any hospital, clinic, dependency program, halfway  house or other medical facility?
 8a:
 8b. Have you, within the past 5 years: 
 8b. used controlled substances such as cocaine, heroin, amphetamines,  barbiturates or hallucinogens?
 8b:
 8c. Have you, within the past 5 years: 
 8c. been treated by or been advised by a physician to seek treatment for  drug or alcohol use?
 8c:
 8d. Have you, within the past 5 years: 
 8d. been advised to have any test (except HIV tests), treatment,  surgery, hospitalization or consultation with a medical professional which  has yet to be completed?
 8d:
 8e. Have you, within the past 5 years: 
 8e. had an application for life or health insurance rated up, postponed,  declined or denied reinstatement?
 8e:
9. To the best of your knowledge or belief has more than one natural parent or sibling died of cancer or heart disease prior to age 60?:
 9:
10. Have you, within the past 24 months, used any form of tobacco or nicotine product, including cigarettes, cigars, pipes, chewing tobacco, snuff, nicotine patches or nicotine gum?*:
 10:  If yes, have you, within the past 12 months, used any  form of tobacco or nicotine  product? 10a:  
11a. Have you, within the past 2 years, engaged in or, in the next 2 years do you plan to engage in:
 11a. any aviation activity other than as a fare-paying passenger on  commercial airlines?
 11a:
11b. Have you, within the past 2 years, engaged in or, in the next 2 years do you plan to engage in:
11b. any form of scuba diving, hang-gliding, cave exploration,  parachuting, mountain, rock or ice climbing, bungee jumping or organized  motor racing?
 11b:
12. Have you, within the past 2 years, had a driver’s license suspended, revoked or been convicted of more than three moving violations?:
 12:
13. Have you, within the past 5 years, been convicted of driving while under the influence of alcohol or drugs?:
 13:
14. Are you currently on probation or have you, within the past 5 years, been convicted of a felony?:
 14:
15. Do you intend to travel, live, or work outside the United States or Canada?:
 15:
List All Dependent Children To Be Insured (If Child Rider Selected)  
B1. Child to be insured: 
1. Child to be insured
 Full Legal Name:
 Gender: 
 Date Of Birth: / /
    Age:    
 Place Of Birth:
 Relationship to Insured:
B2. Child to be insured: 
2. Child to be insured
 Full Legal Name:
 Gender: 
 Date Of Birth: / /
    Age:    
 Place Of Birth:
 Relationship to Insured:
B3. Child to be insured: 
3. Child to be insured
 Full Legal Name:
 Gender: 
 Date Of Birth: / /
    Age:    
 Place Of Birth:
 Relationship to Insured:
B4. Child to be insured: 
4. Child to be insured
 Full Legal Name:
 Gender: 
 Date Of Birth: / /
    Age:    
 Place Of Birth:
 Relationship to Insured:
B5. Does any Child to be insured have any existing life insurance in force or is there an application for life insurance now pending on any Child to be insured? (If yes, please provide name of company and policy number.):
 B5:  If yes, please provide name of company and policy number.
 Name Of Company:  Policy#:  
B6. If this coverage is issued, will any existing life insurance or annuity on any Child to be insured be cancelled, terminated, lapsed or not renewed?:
 B6:  If yes, give full details below.
B7. Does any Child to be insured been diagnosed with or treated by a licensed member of the medical profession for any physical disability, mental retardation or special need?:
 B7:  If yes, give full details below.
B8. Has any Child to be insured been diagnosed with or treated by a physician for any disorder of the heart or has any surgery or hospitalization been suggested which has not yet been completed? :
 B8:  If yes, give full details below.
   
Provide details of any YES answers :
 Show question being answered, the condition(s), the name, address  and  phone numbers(s) of the physician(s) and the prescribed  medication(s)
 Question | Answer....
Preauthorized Payment Authorization Method  
I request that my premium payments be debited  from my bank account as shown: 
 PRE-AUTHORIZED CHECK (EFT):   Name Of Bank:     Routing#:  Account#:  

(As a convenience to me, I authorize Fidelity Life Association, A Legal Reserve Life Insurance Company (“Fidelity Life”) to make electronic debits or other forms of preauthorized withdrawals from my financial institution as indicated below. I understand that if a debit or withdrawal is
not honored by the financial institution, Fidelity Life will consider the premium unpaid. Any debit or withdrawal returned due to insufficient funds may be redeposited by Fidelity Life. This authorization will remain in effect until written notice by the depositor/card holder is received
by Fidelity Life. I further agree that if any such debit or withdrawal is not honored, whether with or without cause, Fidelity Life shall be under no liability whatsoever even though such dishonor results in the lapse of insurance, in accordance with the grace period.)
 
I request that my premium payments be debited  from the credit card shown below: 
 PRE-AUTHORIZED CREDIT CARD:     Credit Card: 
 
Card#:  Expiration Date: / /
   

Important (Please Read)

This information will be transferred to the application which will be emailed to you for your final review and approval by e-signature, before sending to Fidelity Life.
If you need assistance during the information gathering process above, please Call (800) 393-3592, and an authorized agent from our company will return your call.

Thank you.
Sincerely, DelPacific Insurance Services

I declare that each answer and statements given to the questions contained in this application is complete and true to the best of my knowledge and belief. I understand and agree that Fidelity Life will rely on these answers, and the answers and statements I may give in any other form taken as a part of this application as representations and not warranties and that no such statement shall void the policy unless it is contained in a written application and a copy of such application shall be endorsed upon or attached to the policy when issued. I also understand that Fidelity Life reserves the right to accept or deny this application after taking into account whatever information may be available to it, including availability as to coverage by its reinsurers. The coverage will be effective on its date of issue if the: (a) health; (b) avocations; (c) occupation; and (d) any other condition relating to the Proposed Insured are as described in the application. The effective date is the Policy Date shown on page 3.
I, the Proposed Insured, authorize any physician, medical practitioner, hospital, clinic, pharmacy, pharmacy benefit manager or other medical or medically related facility, insurance or reinsurance company, the Medical Information Bureau (MIB), consumer reporting agency or employer to give to Fidelity Life any information they might have regarding the diagnosis, treatment, prescription and prognosis of any physical or mental condition, my driving record, avocations, credit history, insurance history, occupation, character and hobbies, as applicable. To facilitate the rapid transmission of such information, I authorize all said sources, except the MIB, to give such records or knowledge to any agency employed by Fidelity Life to collect and transmit such information. I agree that this authorization shall remain in effect for two years (24 months) from the date that it is signed and that a copy of it shall be as valid as the original. I understand that the information obtained with this authorization shall be used to evaluate my application for insurance. I understand that I, or someone I authorize to act on my behalf, may obtain a copy of this authorization. I also understand that I have the right to revoke this authorization at any time. All or part of such information may be disclosed to a physician of my choosing, my insurance agent, the Medical Information Bureau (MIB), to other persons or organizations performing business or legal services in connection with this application, including reinsuring companies and
as may be required by law.
   
* Please fill in where indicated.
   
   

 


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