Life _ LTD Intake Form

Disability & Life Insurance Intake Form

All information is strictly confidential
Client
Full Name
Date of Birth

MonthDayYear
Date
Home Address
Sex
Phone
Email
example@example.com
Social Security Number
Driver’s License Number
State/ Expiration
Birth State

Occupation
Title
Employer
Employer Address
Current Income
City/State/Zip
Annual Income
Last Year’s Annual
Income Type: (1099/W2)
Estimated Net Worth
Mortgage Balance
Total Current Debts
Current 401(k) Plan
Employee Contribution
Employer Contribution

Policy
Amount Requested
Term or Permanent
Beneficiary
Relationship
Date of Birth

MonthDayYear
Date

Current Provider
Primary Care Physician
Date Last Seen & Why

MonthDayYear
Date
Address

PCP Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code

Inquiries (Yes or No)
Tobacco use within last 3 years?
Used Prescription Medication to assist with smoking cessation
or as a substitute for smoking within last 12 months?
Planned Travel outside US within next 2 years?
Where / Purpose
Dangerous Hobbies? If so, please list
Written agreement to become a part of Armed Forces?
Other Life Insurance Policies? If so, please list
Ever convicted of a felony or currently on parole or probation?
Convicted of DUI within the last 5 years?
Been in vehicle accident that resulted in your fault in the last 3
Number of vehicle tickets in the past 3 years

Current Prescriptions

	Medication	Dosage	Frequency	Prescribing Physician	Reason

Family medical history of parents or siblings prior to age 60:
Should be Empty: