FINANCIAL INFORMATION
If a joint policy is being applied for, complete questions 7 through 10 jointly for both the Proposed Insured and the
Additional Proposed Insured.
7.
8. Estimated Net Worth $
9.
□ Yes □ No At this time are you currently in bankruptcy or have you been the subject of any voluntary or
involuntary bankruptcy proceeding pending within the past 12 months? If yes, please provide full
details including Chapter 7, 11, or 13, date fi led, and date of discharge and dismissal, if any.
10. □ Yes □ No Do you have a prepared fi nancial statement? If yes, please attach a copy.
It is represented that the statements and answers given in this supplement to the application are true, complete and
correctly recorded. It is agreed that this supplement shall be a part of the application to the Company for insurance on
the life of the Proposed Insured and any Additional Proposed Insured, and shall be the basis for any policy issued on
this application.
Signed at on ,
Signature of Proposed Insured
Signature of Additional Proposed Insured
Signature of Witness
Signature of Witness
APE561008T
AGREEMENT OF OWNER IF OTHER THAN PROPOSED INSURED
The Owner agrees to be bound by all statements, answers, and agreements made by the Proposed Insured and any
Additional Proposed Insured in this supplement to the application.
Signed at on ,
Signature of Owner Signature of Witness
If Owner is a corporation, an authorized offi cer, other than the Proposed Insured, must sign as owner, give Corporate
title and full name of Corporation. Corporation Name:
Estimated Past Estimated Past
Current Year Current Year
Year Year
ANNUAL INCOME
Earned Income ASSETS
Annual Salary or Wages $ $ Cash $ $
Bonuses $ $ Real Estate $ $
Other Earned Income $ $ Stocks & Bonds $ $
Total Earned Income $ $ Autos $ $
Personal $ $
Unearned Income Business Equity $ $
Dividends & Interest $ $ Other $ $
Net Real Estate Income $ $ Total Assets $ $
Net Business Investment Income $ $
Other: $ $ LIABILITIES
Other: $ $ Mortgages $ $
Total Unearned Income $ $ Business $ $
All Other Personal $ $
TOTAL ANNUAL INCOME $ $ Total Liabilities $ $
