VFB

6965 Piazza Grande Ave., Suite 211, Orlando, FL Tel: (407)271-4831 - Email: veronica@myvfbinsurance.com
Atendido por:*
Cliente do Office : Yes or No *
Face Amount
Monthly Premium
Insurance Plan
PERSONAL INFORMATION *REQUEST A VALID ID
Name

Full ID NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cellphone
Phone Number
Please enter a valid phone number.
Marital Status
Email Address
example@example.com
Date of Birth

MonthDayYear
Date
Place of Birth
Social Security Number
State
Diver License No.
State & Expiration Date

MonthDayYear
Date
Annual Income
Household Income
Net Worth
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Liquid Net Worth
Employer's Name
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Address

Street Address

Street Address Line 2

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Citizenship
If not US Citizen, Are you Legal Permanent Residence?

YesNo
Date of entry the US
If No, Provide date of entry the US:
Tax ID
Country of ID issuance
Passport No
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For how long agent has known client

Primary Beneficiaries

	Name	% Share	Relation	DOB	SSN
Name
Name
Name
Name

Contingent Beneficiaries

	Name	% Share	Relation	DOB	SSN
Name
Name
Name

Tobacco Use

NoDes
Height
Weight this year
Weight last year
6965 Piazza Grande Ave., Suite 211, Orlando, FL Tel: (407)271-4831 - Email: veronico@myvvfbinsurance.com
DOCTOR INFORMATION
Doctor's Name
Telephone No.
Doctor's Address
Last Date Visited

MonthDayYear
Date
Reason for visit
Results Details
INSURED'S NAME

Medical

	Pre-existing condition	Data diagnosed	Name of Current Medication	Dosage
1
2
3

Father Alive

YesNoAge
If "No" provide the cause of death
Mother Alive

YesNoAge
If "No" provide the cause of death
Brothers / Sisters Number
If "No" provide the cause of death
Brothers / Sisters How many
Alive / Age:
Death / Cause:
CRIMINAL BACKGROUND
YesNo
If "Yes" please provide details
During the last 5 years have you plead guilty to or been convicted of any moving vehicle violations or DUI or have you hada suspended license?
YesNo
OTHER INSURANCES
YesNo
If "Yes" please provide details: Provide the following mandatory information: Company Name, Eff Date, Type of Coverage, Policy Number, Effective Date, Coverage and Premium.
Have you ever applied for life, health, or disability insurance or reinstatement of same, which was declined, postponed, rated or modified in any way?

YesNo
Within the past 12 months have you applied for or do you have any application pending for life or disability insurance?

YesNo
VFB
6965 Piazza Grande Ave., Suite 211, Orlando, FL Tel: (407)271-4831 - Email: veronico@myvvfbinsurance.com
Do you participate in any motor sport, automobile, motorcycle, boat or marathon racing; scuba, skin, sport or sky diving; sports in which you compete against other individuals; parachuting; or hang gliding; BASE (parachute jumping from Buildings, Antennas, Spans (bridges) or Earth) or bungee cord jumping; big game hunting; mountain climbing; cave exploring; rodeos or snowmobiling?

YesNo
Have you been or are you currently involved in any bankruptcy proceedings that have not been discharged?

YesNo
BANK INFORMATION *REQUEST VOIDED CHECK
Bank Name
Routing #
Account #
Draft Date

MonthDayYear
Date
Authorized Signature

Clear
/ hereby declare that the information provided is true and correct. / also understand that any willful dishonesty may render for or immediate termination. refusal of the application
Should be Empty:

PERSONAL INFORMATION *REQUEST A VALID ID

DOCTOR INFORMATION

CRIMINAL BACKGROUND

OTHER INSURANCES

VFB

BANK INFORMATION *REQUEST VOIDED CHECK