PRIVATE GARLOCK CLIENT REWARDS PROGRAM
INSURANCE COVERAGE INTAKE FORM Thank you for taking the time to complete this form. Please note that all of the information you provide is secure and encrypted through SSL. To ensure accurate processing and avoid delays, please carefully review and answer the following questions below. If you have questions or encounter difficulties while filling out this form, please contact your Account Executive for support.
1. Name
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First Name
Last Name
2. Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
3. Mobile Number
*
4. Landline Number
*
5. Contact Email
*
6. How did you hear about us? (First Name, Last Name)
7. Date of Birth
*
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Month
-
Day
Year
Date
8. Gender
Please Select
Male
Female
9. Marital Status
*
Please Select
Married
Single
Divorced
Widow
Other
10. Do you have any children? If so how many?
*
11. Years at Current Home Address
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12. Country of Birth
*
13. State of Birth
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14. Were you born outside the United States? If yes, how many years have you been residing in the United States?
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15. Driver License Number (optional)
16. Driver License State (optional)
17. Driver License Expiration Date (optional)
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Month
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Day
Year
Date
18. List all active policies. Provide company name, policy type (term or permanent) death benefit and year of issuance. If no coverage, place "none" in all four spaces for Company A
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19. Does your Spouse have Life Insurance
*
Please Select
Yes
No
20. If you answered Yes above, please provide Death Benefit Amount
21. Do you use nicotine in any form?
*
Please Select
Yes
No
22. If you used nicotine, please provide approximate quit date
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Month
-
Day
Year
Date
23. Please outline any significant health concerns that could impact your eligibility for insurance coverage (e.g., Cancer, Heart Conditions, Diabetes, etc.). If none, simply indicate "N/A."
*
24. Do you hold a Pilot's License?
*
Please Select
Yes
No
25. Do you engage in Extreme Sporting Activities such as Scuba or Skydiving, Hang-Gliding, Hot Air Ballooning, Mountain/Ice/Rock Climbing, Cliff/Base Jumping, Motorcycle/Motor/Water Vehicle Racing, etc.?
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26. Do you intend to travel or live outside the United States within the next 2 years? (Only list planned travel if arrangements are already booked; if you haven't made any travel plans, the answer is "No").
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27. Have you ever declared Bankruptcy? (If Yes, year of discharge)
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28. Do you participate in regular exercise? (If Yes, please describe)
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29. What is your approximate height and weight?
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30. If you are offered Life Insurance, kindly furnish a list of your designated beneficiary(s) including their Name, Address, Date of Birth, and Relationship to you. Additionally, specify the percentage allocation you wish to assign to each beneficiary.
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FINANCIAL INFORMATION
31. Employer Name (state "Retired" if applicable)
*
32. Employer Address (if applicable)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
33. Number of years in occupation (if employed)
34. Describe Duties (if employed)
*
35. Total estimated gross annual earned Income
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36. Total estimated annual passive income (from all unearned income sources)
37. Total estimated gross annual household income (from all sources, passive and earned)
*
38. Approximate TOTAL NET WORTH (including Primary Residence)
*
39. Estimated Credit Rating: (Excellent, Very Good, Good, Fair, Poor): **Please note: We do not pull credit reports, however certain insurance carriers consider credit when assessing policies. Providing this information helps us match you with the most suitable carriers.**
*
Please Select
Excellent
Very Good
Good
Fair
Poor
Signature
Printed Name
*
Date
*
-
Month
-
Day
Year
Date
*This is not a complete application for Life Insurance*
Submit
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