Life Insurance Questionnaire

Life Insurance Questionnaire
Name*

First NameLast Name
DOB*

MonthDayYear
Date
Last 4 of SSN*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
DL #*
DL state
Height
Weight
Country of birth
Are you a US citizen?*
Employer's name*
Occupation and Duties
# of years at employer*
Annual household income*
Amount of life insurance on spouse
Primary Beneficiary Name*
Relation to you*
Their DOB*
Their home address (if same as yours leave blank)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Their Phone Number*
Please enter a valid phone number.
Contingent Beneficiary
Relation to you
Their DOB

MonthDayYear
Date
Their Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Their Phone Number
Please enter a valid phone number.
Your Primary Physicians name and contact information*
Date and last reason for visit*
Existing life insurance and death benefit?
Parents Ages (Example: Mom-64, Dad- 68)*
Living? (Example: Mom-No, Dad- Yes)*
Do they have/had Alzheimer's, cancer, heart or polycystic Kidney Disease, familial adenomatous polyposis, Huntington's disease, ALS, or Parkinsons?*
If yes what age were they diagnosed?
# of blood related siblings*
Living? Ages*
Do you have any diagnoses?*
If yes name(s) of diagnosis
Are you currently taking any medication?*
If yes, name, dose, and frequency?
Any surgeries in the last 10 years? *
If yes when was this surgery?

MonthDayYear
Date
Who was the doctor that performed the procedure?
Any foreign travel? (tickets purchased)
Any risky activity? (ie rock climbing, skydiving)*
History of DUI?*
Date of DUI

MonthDayYear
Date
Driving Convictions?*
Ever been in rehab?*
If yes, when?
Any Felonies?*
Military Experience?*
Student pilot, Crew, or pilot?*
Have you lot more that 15lbs in the past 12 months?*
Illegal drug use?*
Marijuana use?*
Alcohol use?*
If so how many drinks per week?
Tobacco Use?*
If yes, then what kind?
Ever attempted suicide?*
Hospitalized more than 5 days in the past 2 years?
Have you been able to perform normal work duties for the past 90 days?*
If no, why?
Purpose of insurance (personal or business)*
If insured under 18: parent's full name, DOB, last 4 of SSN & DL#
Siblings must have same face amount as the proposed insured. Confirm whether this is correct or not.
Amount of desired life insurance *
Term, permanent or blend of both?*
Bank routing #*
Account #
Draft Date

MonthDayYear
Date
Address for exam if different from home address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Link for One-on-One Meeting:
Anything else we should know about?
Should be Empty: