Apply for Life Insurance Coverage

Thank you for stopping by FEGLIswap.com and comparing information for individual life insurance products. We are ready to move you through to the next important step in this process...taking the no-obligation life insurance application.

In order for us to submit your file to the carrier for underwriting, all of these questions below need to be answered. We have designed this form to allow these responses to be answered and submitted to us in about 5 minutes or less.

If you would rather give us this information over the phone, please contact our Application Fulfillment Center at 1-866-LIFE-101 (866-543-3101), Option 1.


Section 1 -- Proposed Insured Information

First Name *

Middle Initial

Last Name *

Street Address *

City *

State *

Zip Code *

Sex *

Home Phone *

Cell Phone

Work Phone

Client's EMail Address

U.S. Citizen

Birth Date *

Full Social Security Number

Tobacco Usage


Section 2 - Additional Info from Insured needed

Birthplace (If in US, we only need the state you were born in) *

Drivers License - State Issued *

Drivers License - Number *

Drivers License - EXPIRATION Date Needed *

Approximate Current Height *

Approximate Current Weight *

Name of your Employer *

Occupation *

Number of Years of Employment *

Employer's Address *

Your Duties at Work *

Personal Annual Earned Income *

Personal HOUSEHOLD (total) Income *

Personal Annual Unearned Income *

Personal Total Net Worth *

Do you own Property or have a Mortgage in the US? *
 YES NO

Do you plan to remain in the US? *
 YES NO


Section 3 - New Policy / Beneficiary Information

Please specify the Type of Coverage you're considering. *

Please specify the maximum Amount of Coverage you're considering. *

If you have run an illustration on our website (FEGLIswap.com), please tell us the Insurance Carrier you're considering. *

Please list who will be your Primary Beneficiary *

Relationship to Primary Beneficiary *

Primary Beneficiary's Date of Birth *

If you would like to list a Contingent Beneficiary, please list Name(s), Date(s) of Birth, Relationship(s) and Percentages (or equally) here:


Section 4 - Life Insurance Policy - Inforce Coverage Information

Do you currently have any INDIVIDUAL LIFE insurance currently inforce? (Please do not count the FEGLI plan or other group coverage) *
 YES (please answer the 3 questions below) NO (skip to Section 5)

If question above is YES, please list the Year of Issue, Face Amount, and Insurance Company for EACH policy below:

Will you be replacing any of your INDIVIDUAL life insurance coverage currently inforce (Please do not count the FEGLI plan or other group coverage.)
 YES NO

If Replacement question above is YES, please list the Year of Issue, Face Amount, and Insurance Company for EACH policy you will replace below:


Section 5 - Disability Insurance Policy - Inforce Coverage Information

Do you currently have any INDIVIDUAL Disability insurance currently inforce? *
 YES (please answer the 3 questions below) NO (skip to Section 6)

If question above is YES, please list the Year of Issue, Face Amount, and Insurance Company for EACH Disability policy below:

Will you be replacing any of your INDIVIDUAL disability insurance coverage currently inforce (Please do not count the FEGLI plan or other group coverage.)
 YES NO

If Replacement question above is YES, please list the Year of Issue, Face Amount, and Insurance Company for EACH policy you will replace below:


Section 6 - Underwriting Questions

1) Has either parent or a sibling had a history of cardiovascular disease or cancer PRIOR to age 60? *
 YES (Please explain below) NO (Move to Question 2)

If question #1 is YES, please list the country(ies), city(ies), date, length of stay, and purpose below:


2) Does the Primary Proposed Insured intend to travel or reside outside of the United States or Canada within the next two years? *
 YES (Please explain below) NO (Move to Question 2)

If question #2 is YES, please list the country(ies), city(ies), date, length of stay, and purpose below:


3) In the past 5 years, has the Proposed Insured participated in, or do you intend to participate in: any flights as a trainee, pilot or crew member; scuba diving; skydiving or parachuting; ultralight aviation; auto racing; cave exploration; hang gliding; boat racing; mountaineering; extreme sports or other hazardous activities? *
 YES (Please explain below) NO (Move to Question 3)

If question #3 is YES, please list the activity, the date you last participated, where you participated, and if you have plans to participate in the future below:


4) Has the Proposed Insured submitted an application for life insurance to any other company within the past 90 days or begun the process of filling out an application? *
 YES (Please explain below) NO (Move to Question 4)

If question #4 is YES, please list the company name, amount applied for, and purpose of insurance below:


5) Have you ever had a life or disability insurance application modified, rated, declined, postponed, withdrawn, canceled, or refused for renewal? *
 YES (Please explain below) NO (Move to Question 5)

If question #5 is YES, please list the date and reason below:


6) Have you ever filed for bankruptcy? *
 YES (Please explain below) NO (Move to Question 6)

If question #6 is YES, please list the chapter filed, date, reason, and discharge date below:


7) In the past FIVE years, has the Proposed Insured been charged with or convicted of any driving violations to include driving under the influence of alcohol or drugs? *
 YES (Please explain below) NO (Move to Question 7)

If question #7 is YES, please list the date, state, license # and specific violation below:


8) Has the Proposed Insured ever been convicted of or pled guilty or no contest to a criminal offense or currently have any felony or misdemeanor charge pending? *
 YES (Please explain below) NO (Move to Question 8)

If question #8 is YES, please list the date, state, license # and specific violation below:


9) Is the Proposed Insured an active duty service member of the US Armed Forces, a member of the National Guard or an active reservist of the US Armed Forces, or a dependent of an active duty service member of the US Armed Forces? *
 YES (Please explain below) NO (Move to Question 9)

If question #9 is YES, please provide Pay Grade, Rank, and any known foreign assignments below:


10) Is there any intention that any party, other than the Owner, will obtain any right, title or interest in an policy issued on the life of the Primary Proposed Insured as a result of this application? *
 YES NO


11) Does the Owner or Primary Proposed Insured intend to finance any of the premium required to pay for this policy through a financing or loan agreement? *
 YES NO


12) Is the Owner, Primary Proposed Insured, or any person or entity, being paid (cash, services, etc..) as an incentive to enter this transaction? *
 YES NO

13) Does the client have any surgical procedures that have been discussed but not completed?

14) Does the client take any medication on a regular basis?


Upload Docs to MWLB Express/FEGLIswap.com


Section 7 - Your FREE Paramedical (mini-physical) Appointment

1) Have you COMPLETED your Mini-Physical appointment yet? *
 YES (Please explain below) NO (Move to Question 2)

If question #1 is NO and you are required to complete this test for coverage, please give us a couple of dates and times that will work for you, and we will do our best to get you scheduled with ExamOne.



Acceptance of Terms of Use

By checking this box, you agree that as the Proposed Insured, you believe each of these answers and details to be true and complete to the best of your knowledge and belief. You also understand that any misrepresentation contained in this submission and relied on by the company may be used to reduce or deny a claim or void the policy if: (1) such misrepresentation materially affects the acceptance of risk, and (2) the policy is within its contestable period. Finally, you agree to hold harmless all parties associated with this application for life insurance, including but not limited to FEGLIswap.com, the agent, brokerage operation, application processing center, and carrier. *

We appreciate your business, and look forward to assisting you in completing this life application and getting coverage inforce as soon as possible.

Thank you for your time and attention!

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