Elite Life Plans Life Insurance Questionnaire
By completing this brief form, you’ll help your agent, Courtney Perry (Owner of Elite Life Plans), gather the most accurate and personalized life insurance quotes for your needs. If multiple members of your family are getting insured, please submit a separate form for each person.
Full Name
*
First Name
Middle Name
Last Name
Phone Number
*
Email
example@example.com
State of residence
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Height
*
example: 6'1''
Weight
*
example: 110lbs
What's your gender?
*
Male
Female
Which type of Life Insurance are you interested in?
*
Please Select
Term (temporary policy, 10/20/30 year coverage options)
Index Universal Life (permanent policy, compounds cash growth based on stock market performance)
Whole Life (permanent policy, builds cash value, based on a low fixed interest rate around 2-3%)
Final expense (permanent policy, affordable for older adults 60+, typically 10-25K coverage)
I am unsure and need advice
What’s your main reason for getting life insurance? (you may select multiple options)
*
Protect my family's income in case something happens to me unexpectedly
Build cash value and savings fund
Fund retirement income portfolio
Coverage for mortgage/debt
Leave a cash gift to family when you pass
Cover final expenses (i.e funeral costs and/or any outstanding debts)
Plan for children's education fund and/or major life events (i.e. home purchase, wedding, fund their 1st business)
Become my own bank (via. cash value policy, like an IUL)
Not sure, need additional guidance
How much coverage are you looking for?(Example: $50,000, $100,000, $1 million — just a rough estimate is fine)
*
If you’re not sure, just list a range or tell me what you’re trying to protect (like income, mortgage, or final expenses). I’ll help you figure out the right amount.
What's your occupation?
*
What's your monthly budget?
*
Please Select
$50-$100
$100-$150
$150-$200
$200-$250
$250-$300
$300-$350
$350-$400
$400-$500
$500+
Not sure, but I'm flexible
Do you use tobacco?
*
Yes
No
If yes please describe frequency.
Do you have any health conditions?
List any past or current diagnoses, along with the year diagnosed and current status (e.g., “Type 2 diabetes – diagnosed 2018 – controlled with medication”). This helps us determine which carriers may offer you the best coverage and rate. Indicate N/A if Not Applicable
Are you currently taking any routine medications?
List the name of each medication, the condition it’s used for, and how long you’ve been taking it. Example: “Lisinopril – high blood pressure – 3 years.” This helps us find the most accurate rate for you. Indicate N/A if Not Applicable .
Do you have group life insurance through work?
*
Yes
No
If you have insurance through your job, how much is the coverage and what's the monthly payment amount?
example: 100k/$75 monthly
Do you have life insurance outside of work?
*
Yes
No
If you have life insurance outside of your employer, who's the carrier, what is the policy type (i.e. term 30 yr), how much is the coverage, and what's the monthly payment amount?
example: Nationwide, 30 yr term, coverage 100K, $75 monthly
In the past 5 years, have you had any DUI's?
*
Please Select
Yes
No
In the past 5 years, have you filed for bankruptcy?
*
Please Select
Yes
No
In the past 10 years, have you been convicted of a felony?
*
Please Select
Yes
No
Please add any additional comments or questions:
Submit
Should be Empty: