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Client Info
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2
Health
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3
Coverage
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4
Sign & Generate
Select Carrier
Choose the insurance carrier for this applicationAgent Info
Your details — prints on app & cover sheet
Field types:
You have it — typed onto PDF
Client fills in — highlighted yellow on PDF
Section 1 · Proposed Insured
Address required for mailing serviceMailing Address (if different from residential)
Personal Details
Sensitive Fields
⚠️ SSN will be highlighted yellow on PDF
Section 4 · Beneficiary
Primary
Contingent (optional)
Section 10 · Bank / EFT Info
Required — EFT only
Aetna/Accendo requires EFT bank draft — no check option. If client won't provide, toggle "Client fills in" and the bank section will be highlighted on the PDF.
⚠️ Bank routing & account will be highlighted yellow on PDF
Up to 60 days from today
Section 2 · Health Questions
All default NO — toggle only if YES
Default: All answers are NO. Toggle YES only if the client has that condition. Aetna verifies via prescription database automatically.
Part A — Any YES = Ineligible, do not submit
1A. Confined in / advised to enter hospital, nursing home, SNF, psychiatric or correctional facility?
1B. Receiving / advised home health care or hospice care?
2. Uses wheelchair/scooter or needs assistance with daily living activities?
3A. Past year: used oxygen (excl. CPAP) or had kidney dialysis?
3B. Past year: medical procedure/surgery/test pending or results unknown (excl. HIV)?
4. Ever had organ/bone marrow transplant or amputation due to disease/diabetes?
5. Ever diagnosed/positive for HIV, ARC, or AIDS?
6A. ALS (Lou Gehrig's), Huntington's Disease, or sickle cell anemia?
6B. Alzheimer's, dementia, or mental incapacity?
6C. Congestive heart failure, pulmonary fibrosis, terminal condition, or end-stage disease?
6D. Cerebral palsy, cystic fibrosis, muscular dystrophy, or un-operated heart defects?
7. Past 2 years: chemo or radiation for cancer (excl. Basal/Squamous skin cancer)?
8. More than one occurrence of same or different cancer?
Part B — Any YES → Modified Plan
B1A. Past 2 years: alcohol/drug abuse, illegal drugs, or DUI?
B1B. Past 2 years: diabetic coma, insulin shock, retinopathy, nephropathy, or neuropathy?
B1C. Past 2 years: kidney or liver disease?
B2A. Past year: angina, heart attack, cardiomyopathy, or heart/circulatory procedure?
B2B. Past year: stroke, TIA/mini-stroke, aneurysm, or brain tumor?
Part C — Any YES → Standard Plan; all No = Preferred
C1A. Past 2 years: angina, heart attack, cardiomyopathy, or heart/circulatory procedure?
C1B. Past 2 years: stroke, TIA/mini-stroke, aneurysm, or brain tumor?
C2A. Parkinson's, Multiple Sclerosis, or Systemic Lupus (SLE)?
C2B. COPD, chronic bronchitis, emphysema, or other chronic respiratory condition?
Section 3 · Coverage & Premium
Riders (not available on Modified Plan)
Replacement
Additional Notes
Review & Agent Signature
Agent Signature
Click the button to sign →