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Life Insurance Application Form Template

Simplify Your Life Insurance Application Process Today

Applying for life insurance can feel overwhelming, but our Life Insurance Application Form Template simplifies the process for you. Designed for individuals and families, this template helps streamline your insurance application, ensuring you provide all necessary information with ease. You can quickly gather essential details for underwriting, improve applicant experience, and reduce processing time, all while maintaining compliance with industry standards. Start using the live template to break down barriers to coverage.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Social Security Number (last 4 digits)
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Email address
Phone number
Street address
City
State/Province
Postal/ZIP code
Preferred contact method
Phone call
Text message
Email
Type of coverage requested
Term life
Whole life
Universal life
Not sure
Desired coverage amount
$100,000
$250,000
$500,000
$1,000,000
Other
Please Specify:
If Other coverage amount, please specify
Desired policy term (if term life)
10 years
15 years
20 years
30 years
Not applicable or not sure
Primary purpose of coverage
Income replacement
Mortgage protection
Final expenses
Education funding
Estate planning
Business needs
Other
Please Specify:
Preferred premium payment frequency
Monthly
Quarterly
Semi-annually
Annually
Not sure
Have you used tobacco or nicotine in the past 12 months?
Yes
No
Height (ft/in or cm)
Weight (lb or kg)
In the past 5 years, have you been diagnosed with or treated for any of the following?
Are you currently taking any prescription medications?
Yes
No
If yes, list medication names and related conditions
Primary care physician name
Do you engage in any of the following activities?
Scuba diving
Skydiving or parachuting
Aviation (non-commercial)
Motorsports
Climbing or mountaineering
None of the above
Have you had a DUI or reckless driving offense in the past 5 years?
Yes
No
Family history (parent or sibling) of cardiovascular disease or cancer before age 60?
Yes
No
Prefer not to say
Employment status
Employed full-time
Employed part-time
Self-employed
Unemployed
Retired
Student
Homemaker
Other
Please Specify:
Occupation or job title
Annual household income
Under $25,000
$25,000-$49,999
$50,000-$74,999
$75,000-$124,999
$125,000-$199,999
$200,000+
Prefer not to say
Do you currently have life insurance in force?
Yes
No
If yes, total coverage in force (approximate $)
Have you had any life insurance applications pending or declined in the past 2 years?
Yes
No
Primary beneficiary full name
Allocation percentage to primary beneficiary
Relationship to you
Spouse or partner
Child
Parent
Sibling
Other relative
Trust
Estate
Business partner
Other
Please Specify:
Are you a U.S. citizen or permanent resident?
Yes
No
Do you consent to receive disclosures and documents electronically?
Yes
No
I authorize the insurer to obtain consumer reports and medical information for underwriting purposes.
Yes
No
Electronic signature
Signature date
I attest that the information provided is true and complete to the best of my knowledge.
Yes
No
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Paper art illustration depicting a life insurance application form for FormCreatorAI article

When to use this form

Use this form when you want to apply for new individual or family life coverage, replace an old policy, or increase your amount. It fits first-time buyers, new parents, homeowners, and business owners setting up key person coverage. Agents can send it to clients to pre-qualify and speed underwriting. Provide beneficiaries, coverage amount, and basic health and lifestyle details. If you are coordinating health insurance at the same time, keep answers consistent with the Medical insurance application form. After a death, your beneficiary will start a claim with the First notice of loss form, not this application. If you need to confirm property details for mortgage protection, you may reference the Home insurance declaration form.

Must Ask Life Insurance Application Questions

  1. What coverage amount and term length do you want, and who are your primary and contingent beneficiaries?

    This defines the policy structure and payout plan, so underwriting and pricing match your goals. Listing both primary and contingent beneficiaries prevents delays during a claim.

  2. What is your full legal name, date of birth, and current address?

    Identity and age drive eligibility and rates, and address confirms state-specific rules. Accurate data reduces back-and-forth and speeds approval.

  3. Do you use tobacco or nicotine, and when did you last use it?

    Usage can change your risk class and price more than most other factors. The timing helps determine whether you qualify for non-smoker rates.

  4. What are your height, weight, diagnosed conditions, and current medications?

    These details allow underwriters to assess health risk and decide if labs or records are needed. Keeping answers consistent with your other insurance paperwork reduces delays.

  5. What is your occupation, and do you engage in high-risk activities such as aviation, scuba, or climbing?

    Job duties and hobbies can add exclusions or required riders, ensuring you get clear, accurate quotes. Being specific helps avoid surprises later.

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