Secure Your Future NOW!!!
PART -1- FORM
Please, fill out each form one at a time, and click on "Submit"

First name*

Middle Name (if it shows in your license)

Last name*

Gender*

Male

Female

Birthday*

Month

Day

Year

Hight Feet*

Inches *

10"

11"

12"

Weight (in pounds/ Lb)*

Address*

City/Town*

State*

Zip code*

Email*

Yes, subscribe me to your newsletter.

You will receive updates about your application and or future communications regarding your policy and/or new products.

Phone*

Country of Birth*

Country of Citizenship*

Document of Identification*

Driver's License

Passport

Number (Driver's License or Passport)*

Your information is in a safety field.

Social Security Number *

Numbers only

Your information is in a safety field.

1. - I'm not a US-Citizen, I'm a:*

A - Green Card Holder

B - Employment Authorization Card Holder

C - If other, please explain.

Answer the next field accordingly to your choice.

1.1 - Number of the document selected above (A/B)

Add the number listed on your document.

1.2 - Another document than the two listed above if you checked "C".

"If You are Employed, please fill out the following questions". Company name

Add your workplace here.

Multi-line address

Country/Region

Address

City

Zip / Postal code

I have been with the company for

Less than 6 months

More than 6 months

1 to plus more years

N/A

Insured Annual income

To help determent the right coverage for you.

Your Networth

To help determent the right coverage for you.

Family income

To help determent the right coverage for you.

Position

Phone*

Industry/Field of work. (JUMP To "OTHER" AT THE END IF YOU CAN'T FIND THE RIGHT OPTION)

Advertising Industry

Aerospace

Agriculture and Farming

Antiques and Collectibles

Art

Automotive Industry

Banking & Financial Services

Biotechnology

Building Materials and Supplies

Business Services

Chemical Industry

Cleaning Products and Services

Cloud Computing

Computer Hardware

Construction Industry

Consulting

Consumer Electronics

Consumer Goods

Consumer Healthcare

Crafts

Culture Industry

Data Storage and Management

Defense Industry

Design Industry

Ecommerce

Education and Training

Energy

Entertainment Industry

Environmental Services

Events Industry

Fabrics and Textiles

Fashion Industry

Food & Beverage

Healthcare Industry

Heavy Industry Hospitality

Information Technology

Insurance

Jewelry

Leisure and Recreation

Logistics and Supply Chain

Luxury Goods

Machinery and Heavy Equipment

Manufacturing

Media

Medical Devices and Supplies

Mining

Music Industry

Personal Services

Pet Care and Supplies

Pharmaceutical Industry

Photography

Printing

Professional Services

Publishing

Real Estate

Restaurants and Food Services

Retail

Robotics

Security

Social Media Industry Software

Space

Sports and Fitness

Technology

Telecom Industry

Tools and Hardware

Toys and Games

Traditional Products

Transportation

Travel & Tourism

Utilities

Video Game Industry

Waste Management

Other

****The reason if you are currently unemployed:

What is your current Marital Status?*

Military Status

If you answered "A", we'll collect more information about it later in the process.

Bank Information*

Checking Account

Savings Account

Other

Bank Name*

Full Address*

100 Main St, Boston, MA, 02108

Routing Number*

To be used later for future premium payments. (It can be changed later)

Account Number*

To be used later for future premium payments. (It can be changed later)

<<SMOKER DETAILS>> Within the last 5 years have you used any product containing tobacco or nicotine, including but not limited to cigarettes, e-cigarettes, vape pens, cigars, pipes, chewing tobacco, snuff, nicotine gum and/or nicotine patch?*

<<PERSONAL DETAILS>> Personal Details Have you gained or lost weight during the last 12 months?*

Select all that apply.*

What was the reason for the weight loss? *

Diet, Exercise, Health Condition, other..., please explain.

How much weight (lbs.) have you lost during the last 12 months?*

If you lost more than 55lb, how much? "Skip this question if it doesn't apply to you"

PART- 2 - FORM

Now that you have completed the Part -1- Form, please continue to Part -2- Form, you are almost done.

FAMILY HISTORY<<>> Are you parents still alive?*

Father, YES

Father, NO

Mother, YES

Mother, No

Father's Current Age

Mother's Current Age

Within the past 5 years have you worked less than full time, received or applied for disability or worker's compensation?*

If "Yes", add details.

Other Applications <<>> Within the past 12 months have you applied for or do you have any applications pending for life or disability insurance?*

If "Yes", add details.

Health History - Proposed Insured In the past 10 years have you ever been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for: *

Any disorder or abnormal condition of the heart, including irregular heartbeat, murmur, rheumatic fever, coronary artery disease, heart attack, chest pain, angina, high blood pressure, or high cholesterol? (NO)

If "Yes", add details.

Have you been involved in any discussions about the possible sale or transfer of this policy to an unrelated third party, such as (but not limited to) a life settlement company or investor group?*

If "Yes", add details.

Any disorder or abnormal condition of the circulatory or vascular system, including aneurysm, transient ischemic attack, stroke, carotid artery or arterial disease?*

If "Yes", add details.

Any disorder or abnormal condition of the lungs or respiratory system, including sleep apnea, shortness of breath, asthma, bronchitis, emphysema, chronic obstructive pulmonary disease, tuberculosis, or allergies?*

If "Yes", add details.

Any digestive system disorder, including ulcer, chronic indigestion, hepatitis, cirrhosis, jaundice, or abnormal condition of the liver, stomach, intestine or pancreas, esophagus, gallbladder, or colon?*

If "Yes", add details.

Any disorder or abnormal condition of the brain/nervous system, including seizures/ epilepsy, tremors, falls or imbalance, fainting, dizzy spells, headaches/migraines, loss of consciousness, confusion or memory loss, paralysis, numbness, limited motion?*

If "Yes", add details.

Any disorder or abnormal condition of the eyes, ears, nose, throat, or sinuses?*

If "Yes", add details.

Any disorder or abnormal condition of the endocrine system, including thyroid, pituitary, adrenal or other gland?*

If "Yes", add details.

Any disorder or abnormal condition of the spine, hip, knee, shoulder, back, joints, bones, muscles, arthritis, rheumatism or gout?*

If "Yes", add details.

Any disorder or abnormal condition of the urinary system, including bladder, kidney, or urinary abnormalities such as protein, sugar or blood in urine?*

If "Yes", add details.

Any disorder or abnormal condition of the urinary system, including bladder, kidney, or urinary abnormalities such as protein, sugar or blood in urine?*

If "Yes", add details.

Any disorder or abnormal condition of the genital system, including prostate, testicles, pelvic organs, ovaries, cervix, uterus, or breast?*

If "Yes", add details.

Any disorder or abnormal condition of the skin, including psoriasis, eczema, non-healing wounds, melanoma, nevi or moles?*

If "Yes", add details.

Any depression, anxiety, bipolar, schizophrenia, Attention Deficit Disorder (ADD), autism, Down Syndrome or any other developmental or psychological condition including Alzheimer's, dementia, or Post Traumatic Stress Disorder (PTSD)?*

If "Yes", add details.

Any anemia, hemophilia or disorders of the blood other than Acquired Immune Deficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV)?*

If "Yes", add details.

Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS), or have you tested positive for exposure to or been diagnosed with HIV or AIDS?*

If "Yes", add details.

Any cancer, tumor, polyp, lump, nodule, cyst, lymphoma or any disorder of the lymph nodes?*

If "Yes", add details.

Amputation due to disease or other medical condition?*

If "Yes", add details.

Ataxia, transverse myelitis, myasthenia gravis, autoimmune disorder such as lupus, blindness, or post-polio syndrome?*

If "Yes", add details.

Parkinson's disease, muscular dystrophy, Huntington's chorea, motor neuron disease, Lou Gehrig's Disease (ALS), or multiple sclerosis?*

If "Yes", add details.

Diabetes, high blood sugar, pre-diabetes, impaired glucose tolerance, impaired fasting glucose, insulin deficiency, hyperglycemia, or diabetes associated with pregnancy?*

If "Yes", add details.

In the past 10 years have you used marijuana, cocaine, heroin, or any other illicit drug or controlled substance, been advised by a physician to discontinue or reduce alcohol or drug intake?*

If "Yes", add details.

Have you used drugs not prescribed by a physician, been self-admitted to a drug or alcohol treatment facility, or been a member of a support group such as NA or AA?*

If "Yes", add details.

Has a biological parent or sibling been diagnosed or treated by a health professional for cancer, heart disease, Huntington's Disease, Lou Gehrig's Disease (ALS), or polycystic kidney disease?*

If "Yes", add details.

Do you have any pending appointments with any health care provider or medical facility?*

If "Yes", add details.

Checked by default to continue. <<>> Health History - Proposed Insured (cont.) Within the past 5 years have you:

Consulted with a physician other than your personal physician or had x-rays, electrocardiograms, heart catheterization, mammograms, ultrasounds, biopsy, or any other medical tests and/or procedures, except those related to (AIDS Virus)*

If "Yes", add details.

Been admitted to a hospital, seen in an Emergency Department or been advised by a member of the medical profession to enter a hospital for observation, operation or treatment of any kind?*

If "Yes", add details.

Do you currently: Use or require the use of any mechanical or medical devices such as: a wheelchair, walker, multi-prong cane, hospital bed, dialysis machine, respirator oxygen, motorized cart or stair lift?*

If "Yes", add details.

Need help, assistance or supervision for: bathing, eating, dressing, toileting, walking, transferring, or maintaining continence?*

If "Yes", add details.

Medications<<>> Are you currently taking, or have you taken within the last 12 months, any prescription medications or over the counter drugs, including aspirin and/or herbal supplements?*

If "Yes", add details.

Only include over the counter drugs, aspirin or herbal supplements if being taken for a chronic condition (i.e. Arthritis, Depression, Cardiac/Stroke Risk, etc.)*

Initial Premium Information / Bank Information<<>> I authorize National Life Group to draft the initial premium for this contract

Yes

Effective date of this policy will align with desired draft date.

1-Do you have any existing in force life insurance policy?*

Yes

In force” is an insurance term that means a policy is currently active and providing coverage.

If you answered NO to this question, please move ahead to the BENEFICIARIES after question "5".

2-Name of your current Insurance company

3-Policy Number

4-Amount of Coverage/Face amount?

Exp: $100k / $200k / $300k...+

5-Are you considering on replace your current existing policy?*

Yes

Beneficiary 1 - FULL NAME (FIRST, MIDDLE AND LAST NAME) *

Beneficiary 1 is my:

Wife

Son

Daughter

Brother

Sister

Partner

Family Friend

Other (Please explain)

Perhaps, if you have multiple beneficiaries, we can add them during the policy application upon request.

Beneficiary 2 - FULL NAME (FIRST, MIDDLE AND LAST NAME)

Beneficiary 2 is my:

Wife

Son

Daughter

Brother

Sister

Partner

Family Friend

Other (Please explain)

2 -Primary Doctor's full name:

2.1 -Address

Street /city/state/zip code.

2.2 -Phone

2.3 -Reason and date for the last doctor's appointment?

PART- 3 - FORM

Now that you have completed the Part -1- Form, please continue to Part -3- Form, you are almost done.

Lifestyle Questions<<>> Have you had any moving vehicle violations in the last 3 years, or a suspended license or a DUI in the last 5 years? (Yes) (No)

Have you had any moving vehicle violations in the last 3 years, or a suspended license or a DUI in the last 5 years? (Yes) (No) *

Have you been or are you currently involved in any bankruptcy proceedings (excluding those that have been discharged)?*

Do you participate in any type of racing, scuba diving, aerial sports, mountain climbing, BASE or bungee jumping, or cave exploration?*

Do you participate in any aviation activity other than as a fare paying passenger?*

File upload (Driver's license/ the document you had selected on "FORM 1"

If you have trouble to upload your file, send it by email at wiomar.life@gmail.com

I certify that to the best of my knowledge and belief the answers on the application and in the statement are

true and correct

Today's date:*

Month

Day

Year

Signature*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Secure Your Future NOW!!! PART -1- FORM Please, fill out each form one at a time, and click on "Submit"

PART- 2 - FORM

PART- 3 - FORM

Secure Your Future NOW!!!
PART -1- FORM
Please, fill out each form one at a time, and click on "Submit"