CASS LIFE'S "WEB APPLICATION"
Please complete the following form and click "Submit."

Use tab key to move in questions area, not the enter key.(A formal application must be signed by the applicant. Select "INSTRUCTIONS" from menu above.)

In the box below, please enter proposed insured's full name; address (city & state), contact information; (phone, email, etc.), current age; and occupation; Then, please answer the medical questions below.

Is proposed insured currently bedridden, hospitalized, confined
to a nursing facility or ever diagnosed with a terminal illness:

Has proposed insured been treated for Cancer, Congestive Heart Failure, Stroke, Emphysema, Lung Disease, Disease of the Stomach, Intestines, Kidney or Liver:

Has proposed insured been treated for Acquired Immune Deficiency Syndrome, AIDS Related Complex, or been tested positive for the HIV virus:

Has proposed insured been treated for Paralysis, Convulsions, Disease or Disorder of Nervous System, Bones, Muscles or Joints or use alcohol excessively or narcotics, stimulants, or sedatives:

Has proposed insured been taking any prescribed medication or has any been prescribed ( list drug name & dosage ):

Has proposed insured been to a Doctor in the past three years (If yes, give name & address of Doctor):