Catalyst — Life Insurance & Annuity Application

Let's start with you

Enter your details exactly as they appear on your government ID. This verifies your identity with the carrier.

First name

Required

Last name

Required

Date of birth

Required

Sex

Required

State of birth

Required

Enter a valid email

Mobile phone

Enter a valid phone

Social Security Number — encrypted

Enter a 9-digit SSN

Marital status

U.S. citizenship

Street address

Required

City

Required

State

Required

ZIP

Required

Identification

ID type

Required

ID number — encrypted

Required

Expiration date

Required

Issuing state

Required

Policy owner

The policy owner controls the policy and may differ from the insured. If you're the owner, skip ahead in one click.

I am both the insured and the policy ownerUncheck this if someone else (e.g. a spouse or trust) will own the policy.

Work & income

Carriers use occupation, income and finances to confirm the coverage amount you qualify for.

Occupation

Required

Employer

Work address

Work phone

Years employed

Annual income

Required

Annual expenses

Household net worth

Job duties

Health & lifestyle

Answer as accurately as you can — honesty here protects your claim later.

Common health conditions

Check anything you've been treated for or take medication for. Selecting one opens a few quick questions.

Any other health issues that pertain to you?

Family history

For blood relatives only. If a relative is deceased, include the age and cause.

Has your biological mother or father been diagnosed with heart disease, cerebrovascular disease, cancer, or diabetes at or before age 70?

No Yes

Please choose one

Has any biological sibling been diagnosed with heart disease, cerebrovascular disease, cancer, or diabetes at or before age 50?

No Yes

Please choose one

Coverage & beneficiaries

Tell us what you're applying for and who it protects. Primary shares must total 100%; contingent shares must also total 100%.

Product type

Required

Coverage amount

Required

Beneficiaries

Each group must total exactly 100%.

Annuity suitability & financial profile

Carriers require this to confirm the annuity fits your situation. Answer as accurately as you can — estimates are fine where exact figures aren't handy.

Financial information

Income tax bracket

Approximate total net worth

Liquid assets after annuity purchase

Expected income start age

Expected retirement age

Risk tolerance

Conservative Moderate Aggressive

Liquid assets

Checking & savings accounts

Mutual funds (A & C shares)

Qualified plans (if older than 59½)

Fixed annuity

Variable annuity

Stocks & bonds

Other (mortgage / CD)

Liquid total: $0.00

Non-liquid assets

Life insurance

Mutual funds (B shares)

Employer-based retirement plans (if younger than 59½)

Fixed annuity

Variable annuity

Other

Non-liquid total: $0.00

Source of funds — choose all that apply

Investment objectives — choose all that apply

Investment experience — choose all that apply

Liquidity needs

Account type — choose all that apply

Payment

Will any payment be drafted from your bank account?

No — mailing a check / wire / transfer Yes — one-time bank draft Yes — ongoing auto-deductions

Existing coverage

List any life insurance, annuities, or investment accounts you already hold.

Do you have existing life insurance, annuity, or investment accounts?

No Yes

Please choose one

Premium payment

Your premium is drafted from this account once coverage is approved. These fields are encrypted.

Draft frequency

Preferred draft day — between the 2nd and 28th

Account type

Bank name

Name on account

Routing number — encrypted

Account number — encrypted

Review & sign

Take one last look, then type your full legal name to sign and submit securely.

Electronic signature * — type your full legal name

Required to submit

Date

Please check the box to continue

Let's start with you

Policy owner

Work & income

Health & lifestyle

Coverage & beneficiaries

Annuity suitability & financial profile

Existing coverage

Premium payment

Review & sign

Application submitted