Term Life Insurance Policy Application Form
Personal Details
Full Name
Date of Birth
Gender
Male
Female
Other
Marital Status
Single
Married
Divorced
Widowed
Nationality
Contact Details
Address
City
State
ZIP/Postal Code
Phone Number
Email Address
Policy Details
Coverage Amount
Policy Term (Years)
Payment Frequency
Monthly
Quarterly
Annually
Beneficiary Name
Health Information
Height (cm)
Weight (kg)
Medical History
Do you smoke?
No
Yes
Do you consume alcohol?
No
Yes
Declaration
Declaration
Applicant Signature
Date