Online Applications

To apply online, please select one of our insurance carriers and fill out the application completely. Once we receive your application, we will contact you.
With our easy electronic application process, you will have life insurance coverage as quickly as 24 hours. Fill out the application from the carrier that you have selected through our instant online quote. Once submitted, within 24 hours you will receive an email to be signed through DocuSign. Once you complete the electronic signatures through DocuSign, then the insurance carrier can issue coverage quickly.
Sagicor Application

Sagicor Application

Sagicor Online Life Insurance Application

Section 1 - Fraud Warning and Acknowledgement

Fraud Warning: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

I understand and acknowledge that:

  • This is an application for live insurance coverage on the Proposed Insured, to be issued by Sagicor Life Insurance Company ("Sagicor").
  • To the best of my knowledge and belief, the statements and answers given on this application are true, complete, and correctly recorded.
  • Sagicor will rely on the truthfulness, completeness and corrections of the statements and answers on this application to make its decision as to whether to provide life insurance coverage on the Proposed Insured.
Section 2 - Proposed Insured Information

(If NO, please complete a Foreign Travel & Residence Questionnaire and provide an Alien Registration Number.)

Section 3 - Initial Medical and Personal History Questions
Section 4 - Proposed Owner Information

First, Middle, Last

Section 5 - Proposed Payor Information

Complete if not Proposed Owner

First, Middle, Last

Section 6 - Beneficiary Information

First, Middle, Last

First, Middle, Last

First, Middle, Last

Section 7a - Coverage Selection
Section 7b - Rider Selection

Include First Name, Last Name, Date of Birth, Relationship, Sex, and Social Security Number

Medical and Personal History Information of the Proposed Insured Children

Section 7c - Premium Selection
Section 8 - In Force/Replacement Information

If YES, a replacement form may have to be completed. Please visit www.sagicorlifeUSA.com and check your state's requirements)

Please enter Company Name, Policy Number, Amount, Issue Date, Plan Type, and Applied For (A), Existing (E), or Replacing (R)

Secition 9A - Additional Medical and Personal History Questions

Please provide First Name, Last Name, Phone Number, Mailing Address, City, State, and ZIP

Please respond to the following questions iof you are purchasing a single premium whole life insurance policy.

Section 9b - Family History
Electronic Funds Transfer (EFT) Authorization

Authorization and Acceptance

I hereby request and authorize Sagicor Life Insurance Company ("Sagicor") to make electronic funds transfers from my financial institution as indicated below.n This authorization will remain in effect until revoked by me or by Sagicor upon thirty (30) days written notice. I understand that if a fund transfer is not hoinored by the financial institution, Sagicor will consider the premium unpaid. Any fund transfer returned due to insufficient funds may be re-drafted by Sagicor at its sole discretion. I further agree that if any such fund transfer is not honored, whether with or without cause, Sagicor shall be under no liability whatsoever, even though such dishonor results in the lapse of insurance.

Sagicor reserves the right to revoke this authorization without notice in the event of two (2) consecutive returned fund transfers or a cumulative total of three (3) returned fund transfers in a twelve (12) month period. If this authorization is revoked by Sagicor, it is not eligible to be reinstated for a twelve (12) month period. You must contact Sagicor and request that this authorization be reinstated.

Include Address, City, State, ZIP

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Fidelity Application

Fidelity Application

Fidelity Online Life Insurance Application

Section 1 - Proposed Insured Information
Section 2 - Prequalification Questions
Payment Information

Authorization

By submitting my account information, I authorize Fidelity to withdraw funds from my account for the initial and/or monthly renewal premiums and understand that the amounts may differ. Premium shortages may result from a variety of causes, including underwriting adjustments. I authorize my financial institution to pay from my account to Fidelity any preauthorized bank account withdrawals. I agree that my financial institution shall be fully protected in honoring any such payment and that its rights and responsibilities regarding the payment shall be the same as if the payment were signed personally by me. I agree to notify the business in writing of any changes in my account information. This authorization will be effective until I give you at least three business days' notice to cancel. If notice is given verbally, Fidelity may require written confirmation from me within 14 days after my verbal notice.

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Assurity Application
Proposed Insured

First / Middle / Last

including City / State / ZIP

Years and months

including City, State, ZIP

list occupation and duties

list occupation and duties

Policyowner

Policyowner is the Proposed Insured unless otherwise indicated. If Ownership is a trust, complete the Trust Information/Additional Beneficiary form rather than this section.

First, Middle, Last

including City / State / ZIP

First / Middle / Last

Beneficiaries

(Do not complete if applying for Reversionary Annuity coverage). If Beneficiary is a trust, or if additional space is needed, complete the Trust Information/Additional Beneficiary form.

First/M/Last

First/M/Last

First/M/Last

First/M/Last

Premium Payment

Please answer the following questions. If additional space is needed, attach a separate sheet of paper.

If yes, check all that apply

If yes, provide details below

Please include Company Name, Type of Coverage, and Amount of Coverage

Please include amounts for Father, Mother, and Siblings

Please check all that apply

Please check all that apply

Life Product Section
Term Life Insurance
Whole Life Insurance

(If no option chosen, ETI will apply)

(If no option chosen, PUA will apply)

Single Premium Whole Life Insurance

(If no option chosen, PUA will apply)

Physician Information

Please list the last physician consulted:

Agreement

I (We) have read the above questions and answers and declare that they are complete and true to the best of my (our) knowledge and belief. I (We) agree that this application shall form a part of the policy if attached thereto.

I (We) agree that:
a. In the event the first full premium on the policy applied for is paid upon the date of this application, the insurance under such policy shall take effect as provided in the Temporary Conditional Insurance Agreement delivered by the Company’s agent in exchange for such payment.
b. In the event the first full premium on the policy applied for is not paid upon the date of this application, the insurance under such policy shall not take effect unless: a) The application is approved by the Company at its home office, b) Such policy is issued and delivered to the Proposed Insured/ Owner, and c) Such first full premium is paid during the Proposed Insured’s lifetime and the answers on the application remain true, complete and accurate as of the date the first full premium is paid. When such approval, issue, delivery and payment have occurred, the insurance under such policy shall take effect as of the date of issue specified in the policy.
c. No agent or medical examiner is authorized or has power to change or waive any term, provision or condition of this application, the Temporary Conditional Insurance Agreement or the policy applied for, or to pass upon or approve insurability of any person for whom insurance is applied for.

Any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a substantial civil penalty where and to the extent allowed by state law.

Substitute Form W-9 information (Request for Taxpayer Identification Number and Certification) : I, the Owner (or each Joint Owner), certify under penalties of perjury that the number shown is my correct Taxpayer Identification Number. I am not subject to backup withholding due to failure to report interest and dividend income, and I am a U.S. Person (including a U.S. resident alien). The Internal Revenue Service does not require my consent to any provision of this document other than the certification required to avoid backup withholding.

City/State/ZIP