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We will contact you with a response as soon as we can.

Tell Us About Your Policy

Insurance Company: Policy Face Value ($): Annual Premium ($): Policy Type: Policy Status:

Who Is Insured By The Policy?

Date of Birth: Gender of Insured: Height:

Weight (lbs): Any Major Diagnoses? Health Condition:

Medical History & Lifestyle

Primary Care Physician: Physician Address: Date of Last Visit: Reason for Last Visit: Current Medications: Medical Consultations in Past 5 Years:

Tobacco Use Have you ever used tobacco or nicotine products?

Alcohol Use Do you currently drink alcohol? Have you ever received treatment for alcohol use?

Medical Conditions Assessment

Cardiovascular Health Have you ever been diagnosed with heart disease? Do you have high blood pressure?

Cancer History Have you ever been diagnosed with cancer?

Diabetes Have you been diagnosed with diabetes?

Additional Health & Lifestyle Information

Recent Health Changes Have you lost or gained more than 10 pounds in the past year?

Physical Activity Do you engage in regular exercise?

Mental Health Have you ever received treatment for mental health conditions?

Hazardous Activities & Travel Are you a private pilot? Do you participate in any of these activities? Do you intend to reside or travel outside the US within the next two years?

Family Medical History

Please provide information about your parents and siblings regarding heart disease, cancer, and other significant medical conditions.

Mother Is your mother living?

Father Is your father living?

Siblings Number of Siblings: Has any immediate family member been diagnosed with or died from heart disease? Has any immediate family member been diagnosed with or died from cancer? Other Significant Family Medical History:

Who Owns The Policy?

Is the Insured Also Policy Owner? Is the Policy Owned Through a Trust? Name of Policy Owner: Current Beneficiaries:

Finish Your Application

Your Name: Your Phone: Your Email:

Medical Records Authorization

To complete your life settlement evaluation, we may need to request medical records from your healthcare providers.

I authorize MerlinLife and its representatives to request and review my medical records as necessary for the evaluation of my life insurance policy for settlement purposes.

Preferred Physician for Medical Records:

I have read and agree to the MerlinLife Disclosure & Consent Agreement

By checking this box, you confirm that the information provided is accurate and that you consent to be contacted by MerlinLife, or its representatives, regarding your life settlement inquiry. You also acknowledge that this information may be shared with potential investors and medical underwriters as part of the evaluation process.

I authorize the release of my protected health information in accordance with HIPAA regulations for the purpose of evaluating my life insurance policy for settlement.