Individual Life Proposal Request
Legal Name
*
First Name
Middle Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Gender
*
Please Select
Male
Female
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is this a cell phone or land line?
*
Please Select
Cell Phone
Landline
Mobile Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
It's okay to communicate with me via
Email
Text
Are you a U.S. citizen?
*
YES
NO
Are you legally present in the U.S.?
*
YES
NO
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
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Additional Health Information
Height
*
example: 5'11"
Weight (lbs)
*
Nicotine Usage
*
YES
NO
QUIT
Nicotine Quit Date
/
Month
/
Day
Year
Date
Nicotine Form
*
Cigarettes
Cigars
Chewing Tobacco
Other
Occupation
*
Annual Income
Job Duties
*
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Insurance Information
Plan of Insurance
*
Term years
ROP Term Years
Universal Life
Indexed Universal Life
Whole Life
Unsure
Desired Monthly Budget
Amount of Death Benefit Desired
Riders
Waiver of Premium
Long Term Care
Child Rider
Critical Illness
Accidental Death Benefits
Number of Years (If Term)
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Client History
Have you been treated for any of the following?
*
Alcohol/Drugs
Lung Disorders
Cancer
Sleep Apnea
Diabetes
Hypertension
Depression
Other
None
Treatment Other
*
Additional General Health Details
Any additional information you wish to share
Do you take any prescribed medications?
*
NO
YES
Prescribed Medications
*
In the past 10 years, have you had any of the following motor vehicle related incidents?
*
Moving Violation
Reckless Driving
DUI
License Suspended or Revoked
NONE
Motor Vehicle Incident(s) Details
*
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Additional Comments
Are there any additional comments or notes you'd like to leave us?
*
Please Select
No
Yes
Additional Comments or Notes
Confidentiality Notice
All information contained in this questionnaire is strictly confidential and used solely for seeking benefits to match the best plan for your needs. You can reach us directly anytime at 706-257-5073 or info@michellecrawfordbenefits.com
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