Elite Life Plans Life Insurance Questionnaire

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 NameMiddle NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
State of residence

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Height
example: 6'1''
Weight
example: 110lbs
What's your gender?
Which type of Life Insurance are you interested in?
What’s your main reason for getting life insurance? (you may select multiple options)
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?
Do you use tobacco?
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?
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?
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?
In the past 5 years, have you filed for bankruptcy?
In the past 10 years, have you been convicted of a felony?
Please add any additional comments or questions:
Should be Empty: