Life Insurance Questionnaire
Data form including questions regarding the Proposed Insured’s Medical History, Avocation, Foreign Travel, Tobacco and or Marijuana usage.
Proposed Insured's Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
SSN/TIN
*
Driver's License Number
*
Driver's License Number
*
Driver's License State
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Primary Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the Proposed Insured a U.S Citizen
*
Yes
No
Will the insured own this policy? If no, completion of Ownership section
*
Yes
No
Owner's Name
First Name
Last Name
DOB or Trust Date
-
Month
-
Day
Year
Date
SSN/TIN
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to Insured
Purpose of Insurance
*
Personal
Business
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Proposed Coverage
Additional Carrier or State specific questions may be asked on the drop ticket.
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Coverage Type & Amount
*
Rows
Type
Length
Coverage Amount
Term Insurance
Universal Life
Whole Life
Fixed Annuity
Riders
Accidental Death Benefit
Waiver of Premium
Child Term
# of Units for Child Rider
Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract?
*
Yes
No
Reason for Replacement
Total accidental death insurance in force with all companies
Does the client have any existing or pending life insurance of annuities?
*
Yes
No
Policy Information
Rows
Carrier
Amount
Policy Number
Issue Year
Replacement
Policy 1
Yes
No
Policy 2
Yes
No
Policy 3
Yes
No
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Beneficiary Information
The total should equal 100% per beneficiary type.
Beneficiaries
*
Rows
Name
Relationship
Primary/Contingent
Percent
DOB
SSN/TIN
Beneficiary 1
Primary
Contingent
Beneficiary 2
Primary
Contingent
Beneficiary 3
Primary
Contingent
Beneficiary 4
Primary
Contingent
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Source of Funds
What is the source of funds for the initial premium?
*
What is the source of funds for future premiums?
*
Is the Proposed Insured using income from their spouse/domestic partner to justify the coverage applied?
*
Yes
No
If Yes, what is the spouse/domestic partner’s annual income?
If Yes, how much life insurance does the spouse/domestic partner have in force?
Do the proposed insured and owner read and understand the English language?
*
Yes
No
Is the proposed insured an active-duty service member of the US Armed Forces(including National Guard and Reserve)?
*
Yes
No
Is the policy owner or the person to whom this policy was sold an active-duty service member of the US Armed Forces(including National Guard and Reserve)?
*
Yes
No
Proposed Insured Annual Income
*
Net Worth
*
Engaged in scuba diving, sky sports, mountain, rock, cliff, ice climbing or motorsport events?
*
Have in the last 5 years
Plan to in the next 2 years
Not Applicable
Plans to travel outside the U.S. in the next 2 years?
*
Yes
No
If Yes, When:
-
Month
-
Day
Year
Date
Have flights been booked?
Yes
No
Additional Comments:
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Health Information
Height - Feet
*
Height - Inches
*
Weight
*
(Current weight plus ½ of any weight loss in the last year)
Has the proposed Insured ever been diagnosed with high blood pressure (hypertension)?
*
Yes
No
Does the proposed insured currently take medication or have any history or treatment for high blood pressure?
*
Yes
No
If Yes, what was the proposed insured’s usual blood pressure reading for the past 6 months?
*
If the proposed insured does not know their reading, select the option that best describes their blood pressure over the past 12 months?
Very Well Controlled
Reasonably Well Controlled
Not Well Controlled
Does the proposed insured use or have ever used tobacco or nicotine(Includes cigar use)?
*
Yes
No
If Yes, what type, frequency and when was it last used?
If cigar use, will the insured test positive for nicotine?
*
Yes
No
Has the proposed insured used marijuana in the last 5 years?
*
Yes
No
Frequency
Type
Date Last Used
Has the proposed insured ever had an application for life or health insurance declined, postponed, or rated or offered other than as applied for?
*
Yes
No
Has the proposed insured had more than 3 speeding tickets and/or moving violations in the past 3 years or had a DUI, license suspension or revocation over the past 12 months?
*
Yes
No
Has any parent or sibling of the proposed insured had, been diagnosed with, or died from cardiovascular disease and/or cancer prior to the age 65?
*
Yes
No
Relationship Table
Rows
Relationship
Age at Death or Diagnosis
Type
Result
Individual 1
Cancer
Cardiovascular
Death
Diagnosis
Individual 2
Cancer
Cardiovascular
Death
Diagnosis
Individual 3
Cancer
Cardiovascular
Death
Diagnosis
Individual 4
Cancer
Cardiovascular
Death
Diagnosis
Has the proposed insured ever been diagnosed with or received treatment/advice for any of the following?
AIDS, ARC, HIV Positive
ALS (Lou Gehrig’s Disease)
Alcoholism
Atrial Fibrillation
Barrett’s Esophagus
Bipolar Disease
Cancer (except certain skin cancers)
Crohn’s Disease
Diabetes (including Gestational)
Drug Use
Emphysema/COPD
Epilepsy/Seizure
Gastric Bypass/Lap Band
Heart Attack
Heart Disease
Heart Failure
Heart Valve Replacement
Hepatitis B
Hepatitis C (active)
Kidney Disease
Liver Failure
Lupus
Melanoma
Multiple Sclerosis (MS)
Parkinson’s Disease
Peripheral Artery/Vascular Disease
Rheumatoid Arthritis (RA)
Sleep apnea
Stroke/Transient Ischemic Attack (TIA)
Ulcerative Colitis (UC)
Other
Does the proposed insured currently take any prescription medications?
*
Yes
No
If Yes, provide prescription information such as name & dosage, reason prescribed, and date condition was diagnosed.
Please verify that you are human
*
Submit
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