Life Insurance Questionnaire

Life Insurance Questionnaire
2213 E Grand River Ave Suite B Lansing, MI 48912 844-705-3289

Ryan Heintz - Account Executive Edge Insurance Group / Aaron Robinson - Account Executive Edge Insurance Group
CLIENT INFORMATION
CLIENT NAME
Gender

MaleFemale
Date of Birth

MonthDayYear
Date
Phone Number
Email Address
example@example.com
Address

Street Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Tobacco User

YesNo
Type of Tobacco
Height / Weight
Marital Status

SingleMarriedDivorced/Widowed
SPOUSE'S NAME
Spouse's Gender

MaleFemale
Spouse's Date of Birth

MonthDayYear
Date
Phone Number
Email Address
example@example.com
Address

Street Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Tobacco User

YesNo
Type of Tobacco
Height / Weight
FINANCIAL INFORMATION
1. Do you currently have a mortgage balace?

YesNo
If so, please list the remaining balance
2. Do you currently have any invested assets?

YesNo
If so, please list the total invested
3. Do you currently have any of the following?

Whole Life PolicyDisability PolicyTerm Life PolicyLong Term Care PolicyDisability PolicyOther:
MEDICATIONS

Please list all current medications along with their purpose, dosage, length of usage, and number of times per day:

HOSPITALIZATIONS
Please list all hospitalizations in the past 5 years, including dates, reason and patient's name:
MEDICAL HISTORY

Have you or your spouse ever had or been diagnosed with any of the following?
Heart Attack
YesNo
Date of diagnosis/Hospitalization(s)

MonthDayYear
Date
Treatment
Name
Stroke
YesNo
Date of diagnosis/Hospitalization(s)

MonthDayYear
Date
Treatment
Name
Diabetes
YesNo
If yes, date of diagnosis Treatment

MonthDayYear
Date
Treatment
Name
Arthritis
YesNo
If yes, what type?
Date of diagnosis? Restrictions?

MonthDayYear
Date
Joint Replacements? Injections?
Name
Cancer
YesNo
If yes, what type?
Date of diagnosis and list any limitations

MonthDayYear
Date
Treatment(s)
Name
2. Please list any surgerys that you have undergone
ADDITIONAL INFORMATION
ADDITIONAL INFORMATION
ADDITIONAL INFORMATION
ADDITIONAL INFORMATION
SIGNATURES
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Date
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