Final Expense Life Insurance
"Protect your Family with one last Gift"
Ask how to receive a
Final Wish Guide!
Pre-Application Online Below
Name (First, Middle Initial, Last)
Sex (Male or Female)
Social Security Number
Home Address Street
Date of Birth
Drivers License Number
Drivers License State
Are you a legal resident?
Smoker or Non-Smoker?
Are you bedridden?
Are you in a nursing home?
Do you require assistance?
Are you in a wheelchair?
Do you have AIDS or HIV?
Do you have any disease history?
Are you a diabetic?
Do you need a bone transplant?
Do you have a terminal medical condition?
Have you been advised to have surgery?
How much Life Insurance do you need to cover your final expenses?
Do you want to pay monthly or annually?
Who do you want as your Beneficiary?
Do you have any current Life Insurance?
What carrier or company?
What day of the month do you want your bank draft to occur on 1st or 3rd?
Account Type: Savings or Checkings?
Name of Financial Institution?
Bank Routing Number?
Bank Account Number
Do you have a friend or family member you would like to refer?
Referral Phone Number
You set appointment (Enter Date)
You set time of day (Enter Time)
Do you want a free memorial guide?
Barry S. McCoy, Broker
P.O. Box 44
Kure Beach, North Carolina
"Your Agent for Life"