Thriven Financial

To provide you with an accurate and personalized insurance quote, we'll need some essential information from you.

Rest assured, the integrity and confidentiality of your data are of utmost importance to us. Please review our confidentiality disclaimer below for more details on how we handle and protect your information.

Basic Info

First Name *

Last Name *

Address

City

State

Postal code

Phone *

Email *

* By submitting the form, you are providing expressed consent for Thriven Financial to contact you by telephone, SMS/MMS, and/or email even if you are on a Do Not Call list. Should you have questions or wish to opt-out of communication at any time, please contact us at info@thrivenfinancial.com or text "STOP". Message frequency may vary. Please review our Privacy Policy

Date of birth

Social Security Number

Marital Status

Birth Country

Birth State

Are you a United Stated Citizen?

Weight

Height

Valid Drivers License?

Drivers License #

Employer Name / Company Name

Length Of Employment at Current Company (Years)

Occupation

Brief Job Description

Annual Income

Will you be the Primary Individual Owner of this Policy?

*If no, please provide the primary individual owner’s information:

Full legal name:

Date of birth:

Social security number:

Full address:

Phone number:

Email:

Secondary Individual Owner Info

Is there a Contingent Owner?

*A contingent owner is different than a contingent beneficiary. A contingent owner will take over the policy if you were to pass.

**If yes you would like a contingent owner, please provide the following items on the individual.

Contingent Owner Information Needed:

Full Legal Name:
Date of Birth:
Social Security Number: Phone Number:
Full address:
Email:

Will you be paying the premiums for this policy or will another individual be paying for the premiums?

*If anyone other than yourself will be paying premiums, please provide the individual’s information:

Full legal name:

Relationship to you:

Date of birth:

Social security number:

Full address:

Phone number:

Email:

Beneficiary Info

Primary Benificiary Info

*To designate a beneficiary, the individual MUST have insurable interest in you. This means that they would experience financial loss and hardship should you die. For example, you cannot designate a friend or coworker as a beneficiary unless they have insurable interest in your life.

*If you currently have a spouse and choose NOT to designate them as your PRIMARY beneficiary, you will need to provide their email below for them to sign off on the application, before it is submitted.

*If you have no spouse, and choose to have more than one PRIMARY beneficiary, please list EACH individual’s:

*Please use commas or forward slashes to notate between beneficiaries and their information on each line.

First and last name

Date of birth

Relation to you (Each Benificiary)

Percentage of Benefit (out of 100%)

*If more than 1 beneficiary is chosen, list desired % amount to each, equal to 100%)
**Example (3 beneficiaries listed): Beneficiary #1- 33%, Beneficiary #2- 33%, Beneficiary #3- 34% = 100

Do you want to designate a contingent beneficiary?

*If yes, you must provide the following information:
First and Last Name:
Date of Birth:
Relation to You:
Percentage of Benefit

*If more than one contingent beneficiary, please list all items stated above for EACH individual.

Policy Info

Desired Amount of Death Benefit for this Policy?

Any existing Life Insurance in force?

(If more than one, list all items for each policy)

Company Name:

Type of Policy:

Amount of Benefit:

Will your existing life insurance policy be replaced as a result of this application?

History

Do You Smoke?

In The Past 12 Months, Have You Used In Either Synthetic Or Natural Form, Marijuana(Cannabis) Or Mairjuana Products?

Are You Active Or Inactive Duty Military With Any Branch?

Within the past 2 years, did you fly as a pilot, crew member, or with any duties aboard an aircraft, or is there any intention of doing so within the next 2 years?

*If yes we will reach out to you for further explanation.

Within the past 2 years, did you engage in racing, parachuting, or scuba diving or is there any intention of doing so within the next 2 years?

Have You Ever Had A Driver's License Suspended Or Revoked Or, Within The Last 5 Years Been Convicted Of Or Pled No Contest To Reckless Or Negligent Driving Or Driving Under The Influence Of Alcohol Or Drugs

*If yes, please explain in further detail below (Year of incident, if it was legally taken care of, if it is still pending, and a brief description of the incident.)

Have you ever been convicted of pled guilty or have current charges pending for a felony, or misdemeanor?

*If yes, please explain in further detail below (Year of incident, how many are on your record, if it was legally taken care of, if it is still pending, and a brief description of the incident(s).

Within the past 5 years, have you been declined, withdrawn, or postponed for insurance or had a policy issued other than as applied for?

*If yes, please provide insurance name and reason for denial, withdrawal or postponed status.

Are you currently receiving, or within the past 5 years have you received or applied for, any disability benefits, including Worker's Compensation, Social Security Disability, or any other form of disability insurance?

*If yes, please explain further.

Have you ever used illegal or other habit-forming drugs, except as prescribed by a physician, ever received medical treatment or counseling for, or been advised by a physician to reduce or discontinue the use of alcohol and/or non-prescribed drugs?

*If yes, please describe in detail below.

Will any portion of the premiums for this policy be financed?

Do you have plans to enter into any agreement or contract to sell or assign the ownership of or any beneficial interest in the applied-for policy?

Have you ever declared bankruptcy?

If yes, what year and what chapter?

Medical Info

Do you have a Primary Care Physician?

*If yes, you MUST provide their name, address, and phone number.

Name of Physician:
Name of Practice:
Address:
Phone Number:

Primary Care Physician Info

In the past 12 months, have you been prescribed any medications other than contraceptives? (even if you have not physically taken them)

*If yes, you MUST list medication and reason for taking:

Medications that you are currently taking OR have been prescribed (even if you never physically took them) in the past 5 years:

Have you ever been diagnosed with, treated for, hospitalized for or been advised to seek treatment by a licensed member of the medical profession for any of the following:

High blood pressure, high cholesterol or high triglycerides?

Heart disease or disorder, heart attack, heart failure, heart murmur, angina or chest pain, palpitations, irregular heartbeat or coronary artery disease?

Circulatory system disorder, thrombophlebitis, aneurysm, embolism, peripheral vascular disease or edema?

Chronic headaches, seizures, fainting, dizziness, epilepsy, paralysis, dementia, Alzheimer’s Disease, cognitive impairment, or other nervous system or brain disorder?

Any tumor, masses, cysts, cancer, melanoma, pre-cancerous lesion, lymphoma or disorder of the lymph nodes?

Anemia, leukemia, clotting disorder, or any other blood disorder?

Diabetes or any complications of diabetes, elevated blood sugar, a disorder of the urinary tract or findings of sugar, protein or blood in the urine?

Asthma, emphysema, chronic obstructive pulmonary disease (COPD), shortness of breath, sleep apnea, tuberculosis, sarcoidosis, persistent bronchitis, spitting up blood or any other disorder of the lungs or respiratory system?

Arthritis, gout, fibromyalgia, any disorder of the back, spine, muscles, nerves, bones, joints or skin or a neuromuscular disorder?

Ulcers, colitis (including Ulcerative Colitis), Crohn’s disease, jaundice, hepatitis, cirrhosis, gastrointestinal bleeding, or other disorder of the stomach, esophagus, liver, intestines, gallbladder or pancreas?

Disorder of the testicles, prostate, breasts, ovaries, uterus, cervix, kidney, urinary bladder, kidney failure, reproductive organs, or any complication of pregnancy?

Thyroid, pituitary, or other endocrine or glandular disorder?

Any nervous, mental, emotional, mood, anxiety, depression, PTSD, Bipolar, Schizophrenia, or a psychiatric disorder, or eating disorders?

Lupus, Scleroderma, Multiple Sclerosis (MS), Rheumatoid Arthritis, autoimmune disease, or connective tissue disease?

Carotid artery disease, stroke, mini-stroke or Transient Ischemic Attack (TIA)?

Have you ever tested positive for exposure to the Human Immunodeficiency Virus (HIV infection) or been diagnosed as having ARC or AIDS caused by the HIV infection or other sickness or condition derived from such infection?

Within the past 5 years, have you been treated or examined by a licensed member of the medical profession or been advised by a member of the medical profession to get specified medical care which was not completed, such as any hospitalization, surgery, or diagnostic test, except those tests related to the Human Immunodeficiency Virus (AIDS virus)?

Has any immediate family member (parents, sisters or brothers) died as a result of, or been diagnosed with, heart disease or cancer prior to age 60?

**If you chose YES for ANY of the above medical questions, you MUST explain: Date(s) diagnosed, if it is still a current medical diagnoses, and any medication(s) you take due to the condition(s).

At Thriven Financial, we prioritize the confidentiality and security of your personal information. The details you provide on this form are strictly for evaluating and managing your insurance needs and will not be shared or sold to any third parties. We adhere to stringent data protection protocols to ensure your information is safeguarded against unauthorized access or misuse. By submitting this form, you consent to our collection and use of your information for the sole purpose of providing you with the best-suited insurance solutions, and you confirm the accuracy and completeness of the information provided. For any concerns or inquiries about how we handle your data, please contact us at info@thrivenfinancial.com

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