LIFE INSURANCE QUOTATION FORM
Please fill out the information below for us to generate a proposal that's tailor-fit for your needs.
Name
*
Mr.
Mrs.
Ms.
Atty.
Dr.
Engr.
First Name
Middle Name
Last Name
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Hight
Ft/In
Weight
Most Recent
Mobile Number
*
-
xxx
xxxxxxx
Email Address
*
example@example.com
Can we communicate with you via email/text?
Please Select
Yes
No
Occupation
*
Are you applying for insurance for someone else? (ex: your parent, spouse, children)
*
Yes
No
PROPOSED INSURED'S INFORMATION
Name
*
Mr.
Mrs.
Ms.
Atty.
Dr.
Engr.
First Name
Middle Name
Last Name
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Occupation
*
SETTING YOUR GOALS
This questionnaire aims to evaluate your financial needs
What is your current life stage?
*
Please Select
Single Professional
Married w/o children
Full Nester (w/ dependent children)
Empty Nester (children are already independent)
Retiree
As a single professional, please select which of the following goals is your 1st priority
*
Create wealth
Increase one's standard of living
Money for health and medical emergencies
Caring for aging parents
Other
As a married person without children yet, please select which of the following goals is your 1st priority
*
Money for health and medical emergencies
Protect your partner
Create wealth
Save for the future
Other
As a full nester with dependent children, please select which of the following goals is your 1st priority
*
Ensure college fund for children
Money for health and medical emergencies
Protect your family
Save for retirement
Other
As an empty nester whose children are now independent, please select which of the following goals is your 1st priority
*
Increase retirement savings
Money for health and medical emergencies
Create wealth
Protect your family and assets
Other
As a retiree, please select which of the following goals is your 1st priority
*
Live on interest
Maximize estate for loved ones
Create wealth for children and grandchildren
Money for clean-up fund
Other
Which benefits would you want to be included for your plan? (all benefits are available for kids to adults)
*
Life Insurance
Accident Coverage
Critical Illness Coverage
Daily Hospital Income (cash allowance)
Health Card for hospitalization
What is the Face Amount you are requesting
*
Ex: $5K - 5Mil
Back
Next
Tobacco Usage (Cigarette,Cigar, Vape, Gum, Patch, Chew)
*
Never
Former
Current
Date Stopped
-
Month
-
Day
Year
Date
Type of Tobacco
Cig, Cigar,Vape,Gum, Patch, Chew
Marijuana usage
Please Select
Yes
No
If Yes, How Often
What Type
Smoke, Vape, Edible, Tinture
Have you been previously declined for Life Insurance?
Please Select
Yes
No
If yes, what Carrier and reason for the decline?
U.S. Citizen
Please Select
Yes
No
Are you actively Working?
Please Select
Yes
No
If No, please explain
Retired, Stay-at-home spose, unemployed
Are you receiving Worker's Comp/Disability?
Please Select
Yes
No
Reason for disability?
Have you tested positive for COVID?
Please Select
Yes
No
Date of full recovery
-
Month
-
Day
Year
ie negative test and no symptoms
Does the client have family history (Parent, Sibling) of being diagnosed and/or death prior to age 70 due to cerebral vascular disease or cancer?
Please Select
Yes
No
If yes, please provide details
Within the last 5 years has the client had any moving violations, or DUI/OWI
Please Select
Yes
No
If Yes, please provide details
Any prior convictions?
Please Select
Yes
No
If yes, please explain
Does the client participate in any dangerous activities/avocations
Please Select
Yes
No
Please provide details
ie. pilot, scuba, racing, skydiving, etc.
Is the client intending to travel to any foreign countries in the next 12 months?
Please Select
Yes
No
Please give travel details
Prescip/Meds12mo
Medication
Dosage
Currently Taking?
How Long
Reason
1
2
3
4
5
6
Have you ever been diagnosed by a licensed physician as having any of the following conditions?
Asthma
Yes
No
Frequency of attacked or hospitalization
Smoker?
Yes
No
Stable pulmonary function tests?
Yes
No
Any diagnosis of COPD or Emphysema?
Yes
No
Cancer?
Please Select
Yes
No
Type of Cancer?
What stage of cancer
Type 1
Type 2
Type 3
Type 4
When Diagnosed?
-
Month
-
Day
Year
Date
Date of last treatment?
-
Month
-
Day
Year
Date
Kind of treatment?
PSA
for prostate cancer
If melanoma, clark level and depth of invasion?
COPD/Emphysema
Please Select
Yes
No
Date diagnosed?
-
Month
-
Day
Year
Date
Does client smoke?
Please Select
Yes
No
Stable pulmonary function tests?
Please Select
Yes
No
Any hospitalizations for COPD/Emphysema?
Please Select
Yes
No
Any limitations or shortness of breath?
Please Select
Yes
No
Oxygen use or daily steroid use?
Please Select
Yes
No
What meds, inhalers,or nebulizer?
Diabetes
Please Select
Yes
No
What type
Please Select
Type 1
Type 2
Last A1C?
Any diabetic complications?
Neuropathy
Retinopathy
Nephropathy
Circulatory problems
Insulin use?
Please Select
Yes
No
Start of insulin use?
-
Month
-
Day
Year
Date
What meds?
Heart Disease?
Please Select
Yes
No
Date diagnosed?
-
Month
-
Day
Year
Date
Any of these?
Congestive heart failure
Atrial fibrillation
Heart attack
Chest pain
How about these?
Heart surgeries
Bypass
Stents
Angioplasty
Pacemaker
Valve replacement
Regular follow-ups and/or testing?
Please Select
Yes
No
Last Dr visit?
-
Month
-
Day
Year
Date
Stroke/TIA
Please Select
No
Stroke
TIA
Date diagnosed?
-
Month
-
Day
Year
Date
Any residual effects?
Numbness
Weakness
Pain
Slurred speech
Visual impairment
Any limitations
Please Select
Yes
No
ie. cane, assistance
Any cognitive abnormalities?
Please Select
Yes
No
Sleep Apnea?
Please Select
Yes
No
Date diagnosed?
-
Month
-
Day
Year
Date
Considered?
Please Select
Mild
Moderate
Severe
Stable pulmonary function tests?
Please Select
Yes
No
Client use CPAP/BiPAP
Please Select
Yes
No
Is CPAP/BiPAP hooked up to oxygen?
Please Select
Yes
No
Any other treatment?
Crohn's Disease
Please Select
Yes
No
When Diagnosed?
-
Month
-
Day
Year
Date
Weight stable?
Please Select
Yes
No
What treatment or meds is the client using?
How frequent are the flare ups?
Submit
Should be Empty: