Who are you working with? *
This will ensure proper routing of your form after you complete it.
Choose your agent Luke Tatum Jeremiah Martin Aaron Dowdell Corey Sinz Rob Brayton
This is not an application for life insurance or any other financial product. This form is intended to provide more insight into your personal information and family finances.
If you decide to apply for a product, this information may be used (with your consent) for that purpose as well. Please do not fill this form out unless you have spoken with someone at
Perfect Spiral Capital.
It will take some time to complete. Make sure you have at least 30 minutes (it could take more or less time, depending on the complexity of your situation.)
It may be helpful to look ahead and gather the appropriate documentation before beginning to fill the form out. Policy Owner: Personal Information
In the Policy Owner sections we will deal with the
proposed owner of the policy. This can be the same person as the insured, or it can be a different person. Please ask if you have any questions! Legal Name *
Enter your name as it appears on your Driver's License. Sex *
Male or Female?
Male Female Nicotine Use *
Have you ever consumed nicotine products in any form? (Cigarettes, cigars, vaporized liquid, gum, etc.)?
No Yes Cannabis Use *
Have you ever consumed cannabis products in any form? (CBD creams or oils, marijuana, etc.)?
No Yes Address *
Enter your address as it appears on your Driver's License.
Policy Owner: Past Finances Do you currently work for income? * No Yes Do you currently receive income from any source other than work? *
Examples include dividends form stocks, interest payments, Social Security income, withdrawals from retirement accounts, rental property income, etc.)
No Yes Do you expect your income to change in the next 12 months? * No Yes Net Worth: Policy Owner
Assets Other Asset Sources *
Please briefly describe the sources of any Other Assets. If none, please type “N/A.”
Do you currently have any mortgages? * No Yes Do you currently have any other debts? *
Car loans, credit cards, etc.
No Yes Bankruptcy *
Have you filed for bankruptcy within the last seven years?
No Yes Current Life Insurance Coverage Do you currently have life insurance on your own life? *
(From any source. Personally owned, paid through payroll deduction at work, offered by a credit union, etc.)
No Yes Policy Owner’s Partner: Personal Information
In the Policy Owner’s Partner sections, we will complete the same information for your fiancée or spouse, if applicable. Are you married or engaged to be married? * No Yes Do you have any children? No Yes Do you have any grandchildren? * No Yes Who is the proposed insured? *
Please list the name(s) of any persons you may wish to insure.
Underwriting Concerns *
proposed insured(s), do you have any underwriting concerns other than tobacco and/or cannabis use? Weight, diabetes, high blood pressure, high cholesterol, hazardous occupations, and many other things may impact the risk class of a particular person. We can discuss possible impact on health rating during our next conversation. No Yes Desired Premium Payment
total premium (base policy and Paid-Up Additions) do you want to pay per year, for all policies you want to apply for? This question is not required, but it is extremely helpful for our next conversation. Your answer can (and probably will) change as we continue to talk.
Unless otherwise specified, we will split this budget roughly equally among the proposed insured(s) listed above.