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I am interested in receiving information about obtaining a Final Expense Life Insurance Policy from the Forethought Life Insurance Company, a division of Global Atlantic Financial Group. I acknowledge and understand that Final Expense Life Insurance may provide funds at the time of the insured's death, which may apply toward the purchase of funeral services, cremation services and merchandise, however, the Final Expense Life Insurance Policy does not itself, provide specific funeral services, cremation services or merchandise.

I further acknowledge and understand that the Final Expense Life Insurance Policy is not a preneed contract or an agreement with any funeral establishment for the funeral establishment to provide funeral services, cremation services or merchandise.


Health Questions. Please answer each question.

1. Is the Proposed Insured currently confined to a hospital or receiving hospice care, or within the last twelve months been told by a medical practitioner that he/she should be confined to a hospital or receive hospice care but chose to not follow that instruction?
2. Has the Proposed Insured been advised by a medical practitioner that he/she has a terminal illness or condition, or that his/her life expectancy is twelve months or less?
3. Is the Proposed Insured confined to a nursing home (including custodial care) or other such facility, or within the last twelve months been told by a medical practitioner that he/she should be confined to such a facility but chose to not follow that instruction?
4. During the last five years has a medical practitioner diagnosed the Proposed Insured as having, or been treated for, any of the following:
Alzheimer's/Dementia | Brain Disorder | Circulatory Disorder | COPD | Insulin Dependent | Diabetes | Liver Disorder | Stroke | Blood Disorder | Cancer | Congestive Heart Failure | Heart Disorder | Kidney Disorder | Lung Disorder
5. Have you been tested positive for exposure to the HIV infection or been diagnosed as having ARC or AIDS caused by HIV infection or other sickness or condition derived from such infection?
The submission of this online form is not a contract for purchase in any way. By submitting this online form you understand, and agree, that you will be contacted by a Life Insurance Agent by email or telephone regarding an application for Final Expense Life Insurance.
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