Insurance Information Worksheet

Proposed Insured Information:
Name
Address
Phone Number
Date of Birth
Social Security #
Email Address
example@example.com
Driver's License #
State
Date Issued
Date Expired
City and State Born
Years at Current Address
Household Net Worth (Example: Income of Hsb & Wife)
Employer Phone Number
Employer Company and address
Occupation/Duties & How long at this occupation
Annual Income of proposed insured
Unearned Income (Earnings for Investments)
Any existing individual life insurance either in-force or pending (elsewhere) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No
If “Yes,” TOTAL in-force death benefit coverage
Date in force coverage was issued

Month Day Year
Date
If “Yes,” TOTAL pending death benefit with other carriers
Of the pending death benefit coverage, how much do you intend to accept
*Required Replacement Question:

Is this a Replacement of an existing Policy. . . . . . . . Yes No this will be an additional policy
If “Yes,” existing life insurance carrier name(s)
Date existing policy was issued

Month Day Year
Date
If “Yes,” existing policy number(s) and death benefit(s) amount
More questions:

Does spouse have existing coverage . Yes No, Spouse does not have existing coverage
If “Yes,” how much coverage
More Questions:

Ever filed for bankruptcy? . . . YES No, Never filed for bankruptcy
If yes, When was bankruptcy discharged?
Financial Information

1 . Have you ever sold, assigned, or pledged as collateral a life insurance policy, or an interest in a life insurance policy? . . . . . . . . . Yes No
If “Yes,” please describe
2 . Is there, or will there be, any agreement or understanding that provides for a party, other than the owner, to obtain any interest in any policy issued on the life of the proposed insured as a result of this application? . . . . . . . . . . . . . . . .

Yes No
If “Yes,” please describe
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If “Yes,” please describe

3 . Will the premiums be financed through a loan? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
If “Yes,” please describe
Continue if you need more space...
4 . Will any entity other than a life insurance company be medically evaluating the proposed insured either to obtain financing or to determine life expectancy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No
If “Yes,” please describe
Continue if you need more space
5 . Will the policy, if issued, be placed in a trust? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No
If “Yes,” give details and provide a copy of the trust
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6 . Will a captive insurance company own, control or benefit from this policy in any way? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No
If “Yes,” list lender, duration of loan, and collateral required
If “Yes,” list lender, duration of loan, and collateral required
7 . Will the source of any portion of the premium payments be assets of, or from contributions to, a captive insurance company? . . .

Yes No
If “Yes,” please describe
If “Yes,” please describe
Primary Beneficiary Name
Address
Percentage
Social Security #
Date of Birth

Month Day Year
Date
Relationship
Contingent Beneficiary Name
Address
Percentage
Social Security #
Date of Birth

Month Day Year
Date
Relationship
If more than one beneficiary, provide info and percentages
Health Questions
1 . a) Height
b) Weight
2 . Please provide details for any health issues you have or may have had in the past
continue if you need more space.
3 . Name of Personal Doctor
Date of last medical consultation

Month Day Year
4 . Medications currently being taken
Reason of last medical consultation
Has the Proposed Insured: In the past five years:
5a . Received treatment for, been advised to seek treatment for, or been diagnosed by a licensed medical professional as having a stroke, cancer, tumor, chest pain or heart attack? . . . . . . . . . . . . . . . . . . . . . . . . No Yes 5b. Received treatment for,attended a program or been counceled for alcohol or drug abuse or been advised by a licensed medical professional to receive such treatment? No Yes In that Past 90 Days 6a. Had any surgery, or been advised to have surgery, or been admitted to a hospital or medical facility or been advised by a licensed medical professional for admission to a hospital or medical facility? . . . . . . . . . No Yes 6b. Had any diagnostic test, excluding tests for Human Innumodeficency Virus (HIV), for which the results are unknown, or been advised by a licensed medical professional to have any diagnostic test, excluding tests for HIV, which has not yet been completed. No Yes
Provide details for any “Yes,” responses
continue, if you need more space...

7 . Family History

	Age if Living	Age at Death	Cause of Death
Father
Mother
Brothers
Sisters

Lifestyle Information

1 . Ever applied for insurance or reinstatement that has been declined, postponed, rated, modified or had any such insurance canceled or a renewal premium refused? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes
If “Yes,” please describe
Continue, if you need more space
2 . Ever received or claimed indemnity benefits or a payment from an insurance company, employer or the government for any injury, sickness or impaired condition? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes
If “Yes,” please describe
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If “Yes,” please describe

3 . Ever made any flights as pilot, student pilot, or a crew member of any aircraft? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes
If “Yes,” please describe
Continue, if you need more space
4 . Been convicted of a moving traffic violation, had any traffic accidents, or had a driver’s license revoked or suspended within the past 5 years? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes
If “Yes,” please describe
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Been charged with or convicted of, or currently awaiting trial on the violation of any criminal law? . . . . . . . . . . . . . . . . . . . . . . No Yes
If “Yes,” please describe
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5 . Used Tobacco or nicotine products in any form within the last 5 years? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes
If “Yes,” please describe
Continue if you need more space
6 . Engage in or plan to engage in any form of the following? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If “Yes,” check all boxes below that apply and complete the appropriate form(s) .

Yes No Motorized Racing Parachuting/Skydiving Martial Arts Scuba Diving Mountain Climbing
Budget indicator

Check all that apply
Coverage amount

$5,000.00 - $40,000.00 $50,000 - $100,0000 $150,000 - $500,0000 $More
Monthly Payment limits

$50 - $100 $125 - $200 $225 - $325 $400 - $500 Up to $1000
Goal for this insurance

To cover Final Expenses such as Funeral, Bills, Leave $ for loved one To cover Mortgage or Rent payment To build a nest egg (ex. Tax Free Retirement) Living Benefits All of the above
Financial Information

Complete this now, if you know that you are going to actually apply. Leave blank if you're just getting a quote and assessment, and will decide later, that you are actually applying.
Bank Name
Account Type

Checking Saving Credit Union
Bank Address
Bank Transit /ABA Routing Number
Bank Account Number
Preferred Draft Date

Month Day Year
Date
Do you accept or decline to receive your policy electronically? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Accept Decline
Signature

Clear
All this information is confidential. Your Agent will contact you with proposals and options. So that you will know that it is indeed our agent contacting you, please give a code word; Example the name of your pet or favorite color
Should be Empty:

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Proposed Insured Information:

Health Questions

Budget indicator

Financial Information