Life Insurance Application

Life Insurance Needs Analysis

Thank you for your interest in completing a Life Insurance Needs Analysis. It is a simple form that lets you know how much coverage your family needs to have if something were to happen to you, and there are only a few questions. At the end of the form you will have the option to answer some health questions if you are interested in a quote for coverage for your family or submit the Life Insurance Needs Analysis form without requesting a quote. If you have any questions just call us at 405-447-1011.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
How much would it take to pay off your mortgage?
This is most peoples largest debt. Paying this off for your family if something happened to you would put them in a much better situation.
How much would it take to pay off any other debt you may have like, auto loans, credit cards, ect.
It's a good idea to take care of all of these things too. You wouldn't want to leave this debt behind to be a burden on your family.
What is your annual household income?
If something were to happen to you, your income will disappear immediately. Your remaining family then has two choices that they are faced with immediately, either make more money or live on less, and they can’t do that overnight. They need time to adjust and figure their finances out. Life Insurance experts recommend that families have 10 years of income replacement.
How many children do you have?
We typically build in $100,000 per child. If this was the last thing you ever did for them it would be something you would never regret.
Recommended Life Insurance Coverage for your family:
This is the amount of Life Insurance we would recommend for your family to pay off any debt that you have, replace your income, leave money to your children, and pay for final expenses.
Who are the most important people in your life?
If you were to die today, How much life insurance would you want to leave your loved ones?
How much money do you have to set aside for your family per month? After you pay all your responsibilities, (i.e. mortgage, Car, Bills.)
To begin your Life Insurance application we just need to ask you a few medical and personal questions. Please fill out the information below for the person whom will be covered:
What is your legal name?

First NameLast Name
What is your birthday?
What is your drivers license number?
What is your social security number?
What is your occupation and what is your employers name?
What is your approximate annual income?
How tall are you?
How much do you weigh?
Who is your primary care physician?
What city and state is your primary care physician located in?
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 let us now when the last time you used a tobacco or nicotine product was, what types of products you use, and how long you have used them?
Have you, in the past five years, been admitted or advised to be admitted to any hospital or health care facility; or undergone or been advised to have surgery, biopsies, treatment or medical test?
If yes: where, what for, and what was the result or outcome?
Have you, in the past five years, been diagnosed by a member of the medicalprofession for any illness, disease, or injury?
If yes: what was the diagnosis, when was the diagnosis, who was the doctor that diagnosed you, and if you are taking prescriptions for it we need the name and dosage?
Have you, in the past five years, been prescribed any prescription medication by a member of the medical profession for any illness, disease, condition, or injury?
If yes: we need to know the name, dosage, and how often you take the prescription. What condition was the prescription written for, who the prescribing doctor was, how long you have been taking it, and when did you stop taking it or are you still taking it?
Have you, in the past five years, been disabled, received disability income benefits, or been unable to work or perform and carry out your normal daily functions for any reason other than maternity leave or recovery from minor surgery?
If yes: when, why, and is it an ongoing issue?
Have you ever been treated for, drug or alcohol addition?
If yes: when, where, and what for?
Have you ever attempted suicide?
If yes: when and did you receive treatment?
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)?
If yes: when, where, and what was the ticket written for?
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?
If yes: when, where, and what was the charge, what was the conviction, if on parole or probation when does it end?
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?
If yes: when, what company, and why was it declined?
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?
If yes: what branch, what is your enlistment date, what is your anticipated discharge date? Have you been alerted or received orders for duty outside the US?
Are you currently receiving, or within the next two years do you expect to receive, hazardous duty or incentive pay?
If yes: what are your job duties, where will they be performed, when will they be performed?
Within the next two years, do you plan to work or reside outside the US?
If yes: when, where, how long, and what is the reason?
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, in the past two years, or do you plan to in the next two years, take part in hang gliding, para sailing, para kiting, parachuting, skydiving, ultralight, soaring, ballooning, bungee jumping, rock or mountain climbing, organized racing by automobile, motorcycle, powerboat or snowmobile, or underwater diving?
Within the past 90 days have you been unable to perform the normal duties of his/her occupation for 15 or more working days because of health reasons?
If yes: when, why, and is it an ongoing issue?
Do you have another person that you would like a quote on?
Please answer the personal and medical questions below for the second person you would like a quote on:
What is your name?

First NameLast Name
What is your birthday?
What is your drivers license number?
What is your social security number?
What do you do for work, and what is your employers name?
What is your approximate annual income?
How tall are you?
How much do you weigh?
Who is your primary care physician?
What city and state is your primary care physician located in?
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 let us now when the last time you used a tobacco or nicotine product was, what types of products you use, and how long you have used them?
Have you, in the past five years, been admitted or advised to be admitted to any hospital or health care facility; or undergone or been advised to have surgery, biopsies, treatment or medical test?
If yes: where, what for, and what was the result or outcome?
Have you, in the past five years, been diagnosed by a member of the medicalprofession for any illness, disease, or injury?
If yes: what was the diagnosis, when was the diagnosis, who was the doctor that diagnosed you, and if you are taking prescriptions for it we need the name and dosage?
Have you, in the past five years, been prescribed any prescription medication by a member of the medical profession for any illness, disease, condition, or injury?
If yes: we need to know the name, dosage, and how often you take the prescription. What condition was the prescription written for, who the prescribing doctor was, how long you have been taking it, and when did you stop taking it or are you still taking it?
Have you, in the past five years, been disabled, received disability income benefits, or been unable to work or perform and carry out your normal daily functions for any reason other than maternity leave or recovery from minor surgery?
If yes: when, why, and is it an ongoing issue?
Have you ever been treated for, drug or alcohol addition?
If yes: when, where, and what for?
Have you ever attempted suicide?
If yes: when and did you receive treatment?
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)?
If yes: when, where, and what was the ticket written for?
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?
If yes: when, where, and what was the charge, what was the conviction, if on parole or probation when does it end?
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?
If yes: when, what company, and why was it declined?
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?
If yes: what branch, what is your enlistment date, what is your anticipated discharge date? Have you been alerted or received orders for duty outside the US?
Are you currently receiving, or within the next two years do you expect to receive, hazardous duty or incentive pay?
If yes: what are your job duties, where will they be performed, when will they be performed?
Within the next two years, do you plan to work or reside outside the US?
If yes: when, where, how long, and what is the reason?
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, in the past two years, or do you plan to in the next two years, take part in hang gliding, para sailing, para kiting, parachuting, skydiving, ultralight, soaring, ballooning, bungee jumping, rock or mountain climbing, organized racing by automobile, motorcycle, powerboat or snowmobile, or underwater diving?
Within the past 90 days have you been unable to perform the normal duties of his/her occupation for 15 or more working days because of health reasons?
If yes: when, why, and is it an ongoing issue?
Should be Empty:

Life Insurance Needs Analysis

To begin your Life Insurance application we just need to ask you a few medical and personal questions. Please fill out the information below for the person whom will be covered:

Please answer the personal and medical questions below for the second person you would like a quote on: