Client Intake Form

Please fill out the following form.

Applicant Full Name

Address

Phone

Email (strongly recommended)

Date of birth

Month

Day

Year

State of Birth

Sex

Male

Female

Non-binary

Social Security #

Driver's License #

Driver's License State Issued

Height

Weight

Primary Beneficiary

Name, Address, Phone, Date of Birth & Relationship to you.

Secondary Beneficiary (if you have one)

Name, Address, Phone, Date of Birth & Relationship to you.

Alternate Beneficiary Options

Estate

Trust

Please advise your agent with the additional details.

Do you have any dependents?

Children

Spouse

Please provide dependent information below:

Name, Address, Phone, Date of Birth, Age, & Relationship

Where do you work?

What is your occupation?

Hire Date

Annual Salary

Do you smoke?

Yes

No

How much life insurance coverage would you like?

Do you have a Primary Care Physician?

Yes

No

Primary Care Doctor's Contact Information

Name

Address

Phone

When was you last doctor's visit?

Month

Day

Year

What was the doctor's visit for?

Routine Check-up

Annual Exam

Follow up appointment

Test Results

Have you ever been treated or diagnosed by a medical professional for Acquired Immune Deficiency Syndrome (AIDS) or ever tested positive for antigens or antibodies to an "AIDS" virus?

Yes

No

In the last 5 years, have you been treated for or diagnosed with cancer or any malignancy, including: carcinoma, sarcoma, Hodgkin's Disease, leukemia, lymphoma, or malignant tumor? Cancer does not include basal cell or squamous cell carcinoma?

Yes

No

Have you ever been treated for, or diagnosed with any of the following:

Stroke, heart attack, heart condition, heart trouble (or any abnormality of the heart--including artery disease), diabetes, or any liver disorder?

Kidney (renal) failure or end stage kidney (renal) disease?

Organ transplant

Emphysema

High Blood Pressure, resulting in you now taking 3 or more medications for treatment?

In the last 5 years, have you ever sought advice or treatment for alcohol abuse, been arrested for driving under the influence or while impaired by alcohol, or been arrested for or used illegal drugs or narcotics?

Yes

No

Have you ever received any advice, treatment, or consultation for: any disorder of the central nervous system, Parkinson's disease, Alzheimer's disease, dementia, senility, or organic brain syndrome?

Yes

No

Have you ever received any advice, treatment or consultation for a diagnosis or amyotrophic lateral sclerosis (Lou Gehrig's disease) or multiple sclerosis?

Yes

No

Do you have any existing policies?

Yes

No

If yes, please provide policy details below:

Provide the carrier(s) and policy number(s).

Does this coverage replace or change any existing insurance?

Yes

No

Are both biological parents still living?

Yes

No

If no, please provide details below:

Which parent:

Age:

Cause of Death:

I realize any false statement, false claims or misrepresentation on the Insurance Enrollment Form may result in loss of coverage, restitution fines, or confinement in prison.

I understand that no insurance will be in effect until the policy has been approved and the initial premium has been paid.

CERTIFICATION: I have read the completed Insurance Enrollment Form and the statements and answers that pertain to me and/or my dependents, I certify that these statements and answers are true and complete to the best of my knowledge.

The statements and answers will be used by the insurance company to determine insurability.

Bank Name

Bank Routing Number

Bank Account Number

Credit or Debit Card Number

Expiration Date

CVV Code

Billing Zip Code

I certify that I am actively at work. I certify that my spouse is not currently disabled or unable to work. I certify that I have accurately disclosed me and my spouse's usage of tobacco products within the last 12 months.

The statements and answers will be used by the insurance company to determine insurability. I understand and agree that the coverage that I am applying for may have a pre-existing condition exclusion.

Permission to Electronically Sign Your Name

I agree

I disagree