Life Insurance Intake Form
Personal Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
State of Residence
*
Marital Status
*
Please Select
Single
Married
Divorced
Widowed
Current Occupation
*
Estimated Household Income
*
Coverage Needs and Goals
Reason/s for getting life insurance (check all that apply)
*
Income Replacement
Debt Protection
Final Expense/Burial Cost
Wealth building and tax-free retirement
Legacy Planning
Business Protection
Other: ________________________________________
Desired Coverage Amount($)
Health and Lifestyle Information
Height
*
Weight
*
Tobacco Use
*
Please Select
Yes
No
Former User
Years Quit
Major health conditions (select all that apply)
*
High Blood Pressure
Diabetes
Cancer
Stroke
Cardiovascular Disease
None
Major health condition unlisted
Diabetes Details
Have you been diagnosed with diabetes?
*
Yes
No
Date Diagnosed
-
Month
-
Day
Year
Date
Date Last Treated
-
Month
-
Day
Year
Date
Type of diabetes
*
Please Select
Type 1
Type 2
Gestational
N/A
Are you taking insulin?
*
Yes
No
N/A
If yes, Age insulin use first started?
Is your diabetes controlled?
*
Yes
No
N/A
Total units of insulin taken daily?
What was your last A1C reading?
*
Diabetes complications
*
Neuropathy (nerve damage)
Retinopathy (eye problem)
Nephropathy (kidney disease)
Cardiovascular issues
Poor would healing
Amputation
N/A
Diabetes complication unlisted
Medication and Medical Condition Details
Format: Medication Name - Dosage - Condition Treated - Diagnosis Date - Last Treatment Date; e.g. Sertraline - 10mg - anxiety - May 1, 2024 - January 1, 2025; if none, type N/A
*
Preferred Policy Type (if known)
*
Term Life (temporary; lower cost)
Whole Life (permanent; cash value)
Index Universal Life (IUL) (tax-free growth; flexibility)
Unsure and Need Guidance
Beneficiary Information
Primary Beneficiary Name
*
First Name
Last Name
Relationship to you
Secondary Beneficiary (if applicable)
First Name
Last Name
Additional Notes or Concerns
Confirmation
I confirm that the above information is accurate to the best of my knowledge
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: