Life Insurance Request Form

Your Name

First & Middle NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Is phone number:

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address if different:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Date of Birth

Date

Drivers License Number and Expiration Date

NumberExpiration Date

Drivers License State of Issue

Social Security Number

You can call me with this if more comfortable but I will need it

Height

Exp: 5'8"

Weight

Were you born in the USA?

What state were you born in?

Type N/A if another country

If no or other, please explain

If not applicable, please type N/A

Are you a US Citizen

Are you currently employed?

If yes, please provide employer name, occupation, years experience, and duties

If no to above, type n/a

Annual earned income

Total annual bonuses:

If none or not applicable, place n/a here

What is your estimated Net Worth?

What is the total of your cash and liquid assets?

Do you have any income from investment accounts? If yes, provide total value and income:

What was your total income from all sources in the last calendar year?

Do you have a mortgage on your home? If yes, what is the balance on the loan?

Do you own other real estate? If yes, please describe and provide values:

Please designate at least one beneficiary (if more than one, please provide percentages equal to 100%) Must have name, contact details and relationship:

Must have at a minimum: Full name, relationship and percentage of share. More information the better so we may identify them when needed, i.e. date of birth, address, cell number.

Would you like to designate a contingent beneficiary in the event the primary beneficiary passes before you? Must have name, contact details and relationship:

This would be someone to receive the death benefits if the primary beneficiaries have passed away. Please provide the same details as above.

Have you filed bankruptcy in the past 7 years?

If yes, please provide details.

Have you ever been told by a member of the medical profession that you had, or consulted a physician for, or received medical treatment for, any of the following: disorder of the heart or blood vessels, angina, heart attack, stroke, cancer, tumor, AIDS, AIDS related complex, or any other immunological disorder, drug dependency or alcohol dependency?

Within the past two years have you been hospitalized for more than five days for any reason?

Have you ever applied for life insurance which has been declined, rated or modified in any way?

Within the past 90 days have you been unable to perform the normal duties of your occupation for 15 or more working days because of illness or injury?

Doctor/Primary Care Physician Name

Doctor/Primary Care Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Doctor/Primary Care Physician Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Reason for your last visit

Approximate month and year of last visit

Do you currently have life insurance?

If yes, will this policy replace? How much do you currently have?

Are your parents still living?

If one or both have passed, please provide age and reason

Do you have any siblings?

Are they still living?

If any are deceased, please provide age and cause of death:

If not applicable, please type N/A

Are you taking any prescribed medication?

If yes, please describe name, dosage and how long you have been taking it

If not applicable, please type N/A

Do you have any family history of ongoing illness/disease?

If yes, please describe

If not applicable, please type N/A

Have you been hospitalized in the past 5 years?

If yes, please provide date(s) and reason(s)

Do you drink?

If yes, how much per week?

Have you, in the past five years, used Tobacco or Nicotine products in any form (e.g. cigarettes, pipes, cigars, snuff, chewing tobacco or nicotine delivery device such as gum or patch, etc)?

If yes, please specify type

If Cigar use, how many per month?

Have you, in the past 10 years, had your driver’s license suspended, revoked, pled guilty to, or been convicted of reckless driving, or driving under the influence (DUI/DWI)?

Have you, in the past five years, pled guilty to or had any other driving conviction(s) (e.g. speeding, cell phone/texting, accident, etc)?

Have you, in the past 10 years, pled guilty to or been convicted of a felony or misdemeanor, or are such charges pending against you, or are you currently on parole or probation?

Have you had an application for life, accident, or health insurance, or reinstatement of a policy, declined, postponed, cancelled, or issued other than as applied for?

Are you a member of the military, military reserve or National Guard (active or inactive) or do you have a written agreement to become a member at a future date?

Within the next two years, do you plan to travel, work or reside outside the U.S.?

If yes, Please provide City, Country, Planned departure date, length of trip, reason for travel/visit

If no to above, type na

Have you, in the past two years, flown as a student pilot, pilot or crewmember (or do you plan to within the next two years)?

Have you ever attempted suicide?

How did you hear about us?

Is there anyone else that you wish to receive information on your behalf? If yes, please provide names and contact information:

Upload anything you feel will be helpful

Thank you for your choosing us to assist you with your insurance needs. We are excited to provide you superior service and value.

Dodge Insurance Agency

DodgeAgency@outlook.com

702-827-6007