Life Insurance Questionnaire

Life Insurance Questionnaire
What do you want life insurance to do for you? (Select all that apply)

I want to help my family with funeral expenses and some financial supportI want my family to be fully taken care of for years after I passI want my mortgage to be coveredI’m not sure what I want from it
Death Benefit Amount

150k or Less250k500k1 Million or more
What type of life insurance are we quoting?

10 year term15 year term20 year term30 year termPermanent Policy (Whole or Index Universal Life)Final Expenses OnlyI need help choosing
Primary Insured *

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Date of Birth

MonthDayYear
Date
Gender
Place of Birth
City and State Or Country if Outside US
Marital Status
Height
Weight
Tobacco Use
Employer
Occupation/Title
Est. Income
Primary Beneficiary

First NameLast Name
Medical Issues

CancerHeartDiabetesAIDS/HIVOther
Please Give Additional Details on all Known Medical Issues:
Any Medications Used
Name of Prescription, Dosage, Frequency
Primary Care Physician/Health Care Provider
Name & Address
Parent Info
Age, Living, Medical Issues
Siblings
Do you have current life insurance with work?

Yes, I plan to keep thisYes, I plan to cancel thisNo, I don't have life insurance with workI don't know
If you have life insurance with your work - what is the current coverage amount?
Do you have current life insurance outside of work?

Yes, I plan to keep thisYes, I plan to cancel thisNo, I don't have life insurance outside of workI don't know
If you have life insurance outside of work - what is the current coverage amount?
I understand I have the option to choose various methods of communication, and I understand the risks associated with transmission of information using the communcation methods listed below

Yes - I accept and AGREE to opt-in ** Disclaimer: By providing my contact information to Bray Agency LLC, I acknowledge and give my explicit consent to be contacted via text (SMS and MMS) and receive emails, automated telephone dialing, artificial/pre-recorded calls, video conference for various purposes, which may include marketing and promotional content. Message and data rates may apply. Message frequency may vary. Reply STOP to opt-out. Refer to our Privacy Policy for more information.No - I decline and DO NOT want to receive communication as indicated above (this does not remove me from being able to receive calls and emails regarding updates or notices on my policy)
By signing below, I agree to receive the following communications to the phone numbers(s) and email address(es) shown above, provided on behalf of Bray Agency LLC (and for all companies they represent for the purpose of all insurance and financial services they provide) and their representatives:

marketing calls
text messages (including SMS and MMS messages)
marketing emails
automated telephone dialing systems
artificial/pre-recorded voice
video conference
This agreement extends to alerts and service messages, including information on existing business and services already provided by Bray Agency LLC to my household.

My consent is not a condition of purchase.

I understand standard text message rates may apply. I will not hold Bray Agency LLC liable for any electronic messaging charges or fees generated by this service.

The frequency of these messages may vary based on the needs of my account.

I understand I will have the option to opt-out of receiving the above listed communications at any time by replying stop, or choosing the link to opt-out.

Messages/calls will be sent from:

541-779-4825

541-601-5474

Emails will be sent from authorized personal at Bray Agency LLC from a business email.

No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: