American Family Universal Life Applications Made Simple

If this is a business case, please notify OCI prior to submitting as there may be additional forms needed.

Agent Information
Agency Owner Name:*
First Last
Agency Owner Email:*
Agency Owner Phone:*
Agency Owner SSN:*
Please choose the OCI Sales Executive helping you with this case:*
Proposed Insured Information
First Name:*
Middle Initial:
Last Name:*
Gender:*
- Male
- Female
Phone:*
Email:*
Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Height:
Weight:
Tobacco Use?*
- Yes
- No
Tobacco Use: What type?*
U.S. Citizen?*
- Yes
- No
Birth Date:*
MM slash DD slash YYYY
Birth State/Country:*
SSN:*
Do they have a driver's license?*
- Yes
- No
DL #:*
Expiration:*
MM slash DD slash YYYY
Employer:*
Occupation:*
Income:
Household Income:
Net Worth:
Purpose of insurance:*
Proposed Life Insurance
Carrier:*
Face Amount:*
Underwriting Class Quoted:
Premium:*
Premium Frequency:*
Other Options:
- Waiver of Premium
- Children Term Rider
Children's Rider Face Amount:
Do any of the Proposed Insureds intend to travel or reside outside of the United States or Canada within the next two years?*
- Yes
- No
Please provide details:*
In the past five years, have any of the Proposed Insureds flown as a pilot, student pilot or crew member of any aircraft, or have any intention to do so in the next two years?*
- Yes
- No
Please provide details:*
In the past five years, have any of the Proposed Insureds engaged in motor sports events or racing (auto, truck, motorcycle, boat, etc.); rock or mountain climbing; skin or scuba diving; aeronautics (hang-gliding, sky diving, parachuting, ultra light, soaring, ballooning) or have any intention to do so in the next two years?*
- Yes
- No
Please provide details:*
Have any of the Proposed Insureds ever had an application for insurance modified, rated, declined, postponed or withdrawn?*
- Yes
- No
Please provide details:*
Have any of the Proposed Insureds ever filed for bankruptcy, or have the intention to seek bankruptcy protection within the next 12 months?*
- Yes
- No
Please provide details:*
In the past five years, have any of the Proposed Insureds pled guilty or been convicted of any driving violations to include driving under the influence of alcohol or drugs?*
- Yes
- No
Please provide details:*
Have any of the Proposed Insureds ever been convicted of, or currently charged with, a felony or misdemeanor?*
- Yes
- No
Please provide details:*
Are any of the Proposed Insureds an active duty service member of the U.S. Armed Forces?*
- Yes
- No
Please provide details:*
Is there an intention that any party, other than the listed Owner or Beneficiary, will obtain any right, title, or interest in any policy issued on the life of any of the Proposed Insureds as a result of this application?*
- Yes
- No
Please provide details:*
Does the Owner or any of the Proposed Insureds intend to finance any of the premium required to pay for this policy through a financing or loan agreement?*
- Yes
- No
Please provide details:*
Is the Owner, any of the Proposed Insureds, or any person or entity, being paid (cash, services, etc.) as an incentive to enter into this transaction?*
- Yes
- No
Please provide details:*
Has the Primary Proposed Insured and/or Other Proposed Insured ever used any form of tobacco or nicotine products?*
- Yes
- No
Please provide details:*
Has any Proposed Insured ever been diagnosed with, or sought treatment from a member of the medical profession for any of the following: a heart attack; stroke; coronary artery disease or other heart disease; cancer; diabetes; or disorder of the immune system, including but not limited to Acquired Immune Deficiency Syndrome (AIDS) or infection by the Human Immunodeficiency Virus (HIV)?*
- Yes
- No
Please provide details:*
Has any Proposed Insured, during the last two years: (1) been confined in a hospital or other health care facility (except for childbirth without complications); (2) received medical treatment or counseling for alcohol or drug use; or (3) been advised by a member of the medical profession to have any diagnostic test or surgery not yet performed (except for those tests related to the Human Immunodeficiency Virus (HIV)?*
- Yes
- No
Please provide details:*
Is any Proposed Insured either less than 14 days old or over age 70 1/2?*
- Yes
- No
Please provide details:*
Beneficiary Information
First Beneficiary Name:*
First Last
First Beneficiary Relationship:*
First Beneficiary %:*
Second Beneficiary Name:
First Last
Second Beneficiary Relationship:
Second Beneficiary %:
Replacement Questions
Clients have existing life insurance?*
- Yes
- No
Is this replacing another policy?*
- Yes
- No
Carrier:*
Policy #:*
Face Amount:*
Type of Plan:*
- Term
- Permanent
Effective 9-20-2021: It is a requirement that we submit a signed illustration dated on or before the electronic application signed date. Please upload a pdf by clicking the box below.*
Max. file size: 100 MB.
E-App Submission*
- By checking this box you are giving OCI permission to submit an e-app with you being listed as the agent of record.
CAPTCHA

If after clicking the submit button if you do not see your request has been submitted, a problem may have occurred so please contact lifesales@ociservices.com to make sure the e-app was received.

American Family Universal Life Applications Made Simple

Agent Information

Proposed Insured Information

Proposed Life Insurance

Beneficiary Information

Replacement Questions