INFORMATION

(1)  Fill in this form as completely as possible, so you may obtain your BEST RATE, then:

(2)  Click the "submit" button at the end of this form;

(3)  A customer service representative will complete an application for you based on the information you provide on this form and will call you to verify receipt of your request and answer any questions you might want to ask;

(4)  The completed application will be mailed to you for your signature;

(5)  You may then return the application to us for final processing.  This process will take 4 to 8 weeks.  It may possible for you to have "no cost conditional coverage" while waiting for your approval, IF...

(a) you are insurable at "standard-healthy rates", and,

(b) IF you submit a check for one month's premium with your application. The conditional coverage will be extended unless you are determined to be uninsurable at normal standard rates. (No ratings or adverse health);

(6)  You may have your policy delivered to you by one of the insurance company representatives, or we can mail it to you for your approval.  Remember, that there is no obligation, and that you will have a "10 day free look" with Illinois Mutual Life or a "20 day free look" with The Life Investors Insurance Company of America, which means you can return the policy within 10 or 20 days, respectively, for a "no-obligation" full refund.

Thank You for your patronage, and we look forward to serving your Mortgage Protection needs and ask about life insurance or investments needs, as well!

The Mortgage Insurance Processing Center

Information.   Please use 'drop down menus' below:

Amount of Coverage Desired                                   ($50,000 Minimum)

I am requesting a "REALQUOTE", only                 Please check one
I am Applying  for Coverage                                  

Proposed Insured

                    Last Name                                                

                    First Name                                                           M.I.

                    Residence Address                                

                    City                                                            State Zip

                    Area Code / Home Phone                          

                    Area Code / Work Phone                          

                    Occupation and Job Title                      

                    Employer's Name                                    

                    Employer's Address                               

                    Date of Birth  (Mo/Day/Yr)                           Age         State of Birth

                    Height                                                        Weight

                     Weight lost in past year, if any           

                    Have you smoked cigarettes in the past 12 months?                                                       

                    Have you used any other tobacco products in the past 12 months?                            

Medical Information       (To receive your best rates, please completely fill in all the requested information)

Have you ever:

Been discharged from the armed services for a physical, mental or other reason?                                                                                           

Had life, health or accident insurance declined, postponed or offered differently than applied for?                                                           

Been treated, counseled or join a group due to drug or alcohol use or abuse or been advised by a medical practitioner to do so?    

Used heroin, cocaine, marijuana, barbiturates or other controlled substances?                                                                                              

Have you ever had or been told by a medical practitioner that they had or have been treated for:

Disorder of the back, muscles, knees, bones or joints; gout or arthritis; deformity or amputation?                                                              

High blood pressure, heart murmur, chest pain, heart attack, angina, stroke, rheumatic fever, varicose veins, phlebitis,

coronary artery disease or any other disorder of the heart or blood vessels?                                                                                                     

Cancer, cyst or tumor?                                                                                                                                                                                                   

Brain or nerve disease, dizziness, fainting, convulsions, headaches, unconsciousness, paralysis, mental disease or nervous
disorder including emotional problems, anxiety, depression or psychiatric treatment or counseling?                                                       

Shortness of breath, persistent or chronic cough, asthma, chronic bronchitis, emphysema or any other lung or respiratory                                                                             disorder?                                                                                                                                                                                                                          

Hepatitis, jaundice, ulcer, hernia, colitis, recurrent diarrhea, rectal disease or disorder of the stomach, intestines, liver,
gall bladder, pancreas or spleen?                                                                                                                                   
                                                                                                                                                                                             
Sugar, blood or albumin in urine; sexually transmitted or venereal disease, kidney stone; disorder of bladder, prostate,
kidney, reproductive organs; or any other disorder of the generative or urinary system?                                                                              

Diabetes, thyroid or other glandular disorders?                                                                                                                                                     

Disorder of eyes, ears, nose or throat?                                                                                                                                                                       

Disorder of the skin or lymph glands; allergy?                                                                                                                                                        

Are you now pregnant?                                                                                                                                                                                                 

If pregnant, Expected delivery date                        

Have you ever had a Cesarean section or complications or pregnancy?                                                                                                           

Have you every been told by a medical practitioner that you have Acquired Immune Deficiency Syndrome (AIDS), AIDS
Related Complex (ARC), or AIDS related conditions?                                                                                                                                           

Have you ever received treatment in connection with any of the categories mentioned above?                                                                    

Have you ever tested positive to the AIDS virus?                                                                                                                                                     

Have you, during the past 5 years, other than as already stated above:

Seen a physician, surgeon, chiropractor or other practitioner for a check-up, consultation, illness, injury or surgery?                        

Been a patient or confined in any hospital, clinic, sanitarium or any other medical facility?                                                                       

Had an electrocardiogram, stress test, echocardiogram, angiography, x-ray, blood studies or other diagnostic test?                           

Been advised to have any diagnostic test, hospitalization or surgery which was not completed?                                                                

Do you have a parent, brother or sister who has had cancer, heart trouble, stroke, high blood pressure, diabetes or tuberculosis?  

Within the past 3 years:

Have you flown as a pilot, crew member or student pilot; or is such flight activity planned in the next 12 months?                        

Have you engaged in mountain or rock climbing, vehicle racing, scuba, skin or sky diving, or hang gliding; or is such activity
planned in the next 12 months?                                                                                                                                                                                   

My Preference for Premium Payments is      

I declare and agree that:

(1) all statements and answers contained herein are true and are correctly recorded to the best of my knowledge and belief, and that

(2) This is only an "application for information for coverage" and that no coverage is implied and none is offered by completing and submitting this form, and that

(3) A customer service representative will contact me by telephone to complete and / or verify this application and that a completed application will be sent to me for my review and signature, and

(4) coverage will commence only upon approval of my application by the insurance company and by my final acceptance of the issued policy.  I also understand that I will have 20 days (know as a 20-day free look provision) after receiving my policy, to decide whether to accept or decline the coverage.

Typed Name of Applicant  

Date                                                

(Please Note:  We do not store nor do we disclose your ip address or other personal information. Your information is confidential and is treated with all privacy and confidentiality.  However, we collect ip addresses of spam and other malicious or annoying inquiries or e-mails)

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