Life Insurance Form - Nucleus Insurance

Home
Insurance
Pay
Contact Us

PersonalInformation
1
Proposal
2
Proposed Insured'sInformation
3
AdditionalInformation
4

2026 Insur3me Insurance Solutions. | All Rights Reserved.

Personal Information

First Name

Last Name

Date of Birth

Primary Address

Phone number/Cell

Email

Driver's License Number

Occupation

Employer

Length of time with employer

Annual Gross Income $

Marital

Spouse's annual income $

Household monthly expenses

Have you ever filed for bankruptcy

Yes

No

Detail

Information for Insurance Proposal

Primary Beneficiary

A primary beneficiary is the person first in line to receive the death benefit from your life insurance policy.

Yes

No

Name

DOB

SSN

Address

Contingent Beneficiary

A contingent beneficiary is a beneficiary of proceeds or a payout if the primary beneficiary is deceased or unable to be located.

Yes

No

Name

DOB

SSN

Address

% for each

Any life, disability, or annuity policies currently in-force?

Yes

No

Replacement?

Yes

No

List carrier(s), death benefit amount, policy number, issued date and if replacement and/or 1035 exchange:

Plan of Insurance requested

Term

Permanent

Yrs

Primary goal to build cash or low premiums

Death Benefit Amount $

Expected Premium Pymt $

Premium Frequency

Proposed Insured's Information

Height

Weight

Nicotine or Marijuana use

Former Use

List each type

Quantity and frequency used

Date of last use

Medical History

Have you ever had, been told you had, or been treated for any of the conditions listed?

Yes

No

Acquired immune deficiency syndrom

Heart murmur/valve disease

Alcohol abuse

Hepatitis

Alzheimer's/dementia/cognitive impairment

Asthma

Cancer*

Cirrhosis

COPD

Coronary artery or cerebrovascular disease

Crohn's disease

Depression/anxiety

Diabetes **

Drug abuse

Epilepsy

Internal organ transplant

Irregular heartbeat/palpitations

Kidney disease

Lupus

Multiple sclerosis

Peripheral vascular disease

Rheumatoid arthritis

Sleep apnea

Stroke

Other

If Cancer

Yes

No

Date

Type

Stage/Grade

Treatment

If Diabetes

Yes

No

Diabetes Type

T1 Age at Onset

T2 Age at Onset

A1C score

Prescription Medications

Please list any prescription medications, dosage, and purpose if not listed previously

Family History

To your knowledge, is there any family history (parent or siblings) of death due to heart disease or cancer under age 60?

Yes

No

Provide Details

Citizenship/Residency/Travel

U.S. Citizen

Yes

No

Citizen of

VISA Type

Expiration Date of VISA

Green Card Status

Length of time in USA

Any future plans to live or travel outside the USA?

Yes

No

Purpose

Cities

Countries

Fequency

Duration

Notes/Comments

Thank you for filling out your information

Terms and Conditions

Authorization:

By signing this form, you authorize nucleus insurance to charge your credit card for the total payment amount specified above. This is a one-time payment for insurance-related services/products.

Non-Refundable Payment Policy:

Due to the nature of this payment for insurance-related services/products, all payments are final and non-refundable. You acknowledge and agree that no refunds will be issued for any reason, including but not limited to cancellation, changes in circumstances, or dissatisfaction with services/products.

Card Processing Fee Disclosure:

A 4.6% card processing fee will be applied to all payments made using a credit or debit card. By submitting this form, you acknowledge that this fee is non-refundable and agree to pay the total amount, including the processing fee. If you wish to avoid this fee, alternative payment methods (e.g., ACH, wire transfer) may be available. Please contact us for details. Payment Processing: Payments are securely processed through our payment gateway in compliance with PCI DSS standards. Your payment information will not be stored beyond what is necessary for processing the transaction.

Disclosures

No Refunds: By submitting this form, you acknowledge that all payments made to nucleus insurance are final and non-refundable due to the nature of the insurance-related services/products.
Card Processing Fee: A 4.6% processing fee applies to all payments made via credit or debit card. This fee is non-refundable and reflects the cost of processing card transactions.
Electronic Signature Consent: If submitting this form electronically, you consent to the use of your electronic signature and agree to conduct this transaction electronically.
Legal Jurisdiction: This authorization is governed by the laws of the United States.
Fraud Warning: Providing false information or unauthorized use of a payment method is subject to legal penalties.

Definition

Pays medical bills and lost wages for employees injured or sickened on the job.

Why It’s Essential

Required by law in most states. Protects your staff from work-related injuries and shields your business from costly employee lawsuits.

Definition

Covers claims like wrongful termination, discrimination, harassment, or retaliation.

Why It’s Essential

Even small teams can face HR issues. EPLI ensures you’re protected against claims by current or former staff and covers legal costs.

Definition

Covers damage to your building, equipment, and furnishings from fire, theft, storms, and more. May include loss-of-income coverage.

Why It’s Essential

Your facility is your lifeline. Property insurance helps you repair, replace, and keep operating after a disaster.

Definition

Covers liability and damage involving business-owned or employee-used vehicles.

Why It’s Essential

Whether you own a van or staff use personal cars to drive residents, accidents happen. This policy ensures your business is covered no matter who’s driving.

Definition

Covers breach response costs, legal defense, and regulatory fines related to data hacks and cyber attacks.

Why It’s Essential

You store private information about residents and staff. This policy protects your finances and your reputation if that data is ever compromised.

Definition

Adds extra coverage above your existing liability policies.

Why It’s Essential

A major lawsuit can exceed your standard policy limits. Umbrella coverage steps in to cover the rest—protecting your assets and business continuity.

Definition

A broader policy covering claims of physical, emotional, or verbal abuse—not just sexual misconduct.

Why It’s Essential

Residents may misinterpret disciplinary actions or house rules. This policy defends you against claims and keeps your business financially protected.

Definition

Covers legal costs and settlements if someone is accused of sexual abuse or inappropriate behavior within your operations.

Why It’s Essential

Even an unfounded accusation can destroy your reputation. This coverage is mandatory in many programs and protects your business against one of the most serious liabilities you can face.

Definition

Also called E&O, this protects against claims of negligence, mistakes, or failure to perform professional duties. It pays legal fees and any damages awarded.

Why It’s Essential

If a resident relapses or gets hurt, their family could accuse you of failing to supervise properly. E&O protects you from these high-stakes claims not covered under general liability.

Definition

Protects your sober living home from claims of bodily injury, property damage, and advertising injury caused to third parties. Covers medical expenses, legal defense, and settlements.

Why It’s Essential

Residents, families, and service providers are constantly coming and going. A single visitor slipping on your stairs can lead to major legal expenses. This policy is often required for certification and provides a critical safety net.