Why Join ASMBA?
Get $5,000 AD&D Insurance
ASMBA

Choice Level Term Plus

Basic Information



       
- -   Why Do We Need This?
Contact Information




- -


Current Status
USAF   USA   USMC   USN   USCG
USPHS   NOAA   MMR  

Full-Time Active
National Guard
Reserve ( Including IRR)
Honorable Discharge (not military retired)
     When?
Military Retired
     When?
Assigned IRR
     When?


Biometrics

Yes   No
Permanent Address




- -
Beneficiary Information

Spouse Information

       
- -   Why Do We Need This?
Yes   No


Yes   No
Spouse's Beneficiary Information

Desired Term & Coverage 10 Year   20 Year   30 Year
$300,000   $350,000   $400,000
$450,000   $500,000

10 Year   20 Year   30 Year
$300,000   $350,000   $400,000
$450,000   $500,000

Application Questions
Note: Please Answer All Questions Below.

In the last 10 years, has the applicant for coverage had a life or health insurance application declined, postponed, modified, or rated?

Yes   No
Yes   No

Had or been treated by a physician or consulted with a health advisor for any of the following:

1. High blood pressure, chest pain, heart attack, or other heart or blood vessel disorder?

Yes   No
Yes   No

2. Disorder of the kidney, bladder, urinary tract, genital tract, or reproductive system?

Yes   No
Yes   No

3. Diabetes, thyroid disease, pituitary or other gland disorder? Ulcers, hepatitis, colitis, severe indigestion, disorder of pancreas, liver, esophagus (gullet), stomach, intestines or colon?

Yes   No
Yes   No

4. Cancer or other malignant disease?

Yes   No
Yes   No

5. Disorder of the blood, lymph glands, or connective tissue?

Yes   No
Yes   No

6. Disorder of the lungs or respiratory system, asthma, tuberculosis, chronic cough or shortness of breath?

Yes   No
Yes   No

7. Mental health problems, nervous system disorder, significant depression, loss of consciousness, paralysis, multiple sclerosis, or convulsive seizures?

Yes   No
Yes   No

8. Alcoholism or advised to reduce or discontinue use of alcohol for health reasons; or been arrested for driving under the influence of alcohol or while intoxicated?

Yes   No
Yes   No

Used marijuana, cocaine, heroin, barbiturates, hallucinogens, or amphetamines unless on prescription of a physician?

Yes   No
Yes   No

Been diagnosed by a physician or tested positive for Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC), or AIDS-related conditions?

Yes   No
Yes   No

In the past 10 years had any treatment and/or evaluation by a physician or any other health care practitioner or is any such treatment or evaluation contemplated?

Yes   No
Yes   No

Have you used any tobacco or nicotine products (including nicotine patch, gum or spray) in the past 12 months?

Yes   No
Yes   No

Did mother or father of applicant die before age 60 of cardiovascular disease?

Yes   No
Yes   No

Is applicant receiving disability pay?

Yes   No
Yes   No

If you answered "yes" to any of the above questions, please provide complete details, including date of diagnosis and physician's name and address.

List each prescibed medicine you are now taking on a regular or frequent basis:

 

 

Copyright 2014 Armed Services Mutual Benefits Association. All Rights Reserved. Not available in the state of Utah.

About Us | Our Plans | Links | Forms | Career Center | Contact Us | Privacy Policy | Site Map