Universal Life Insurance Inquiry Form

Personal Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Gender
Marital Status
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health & Lifestyle Details
Do you use tobacco or nicotine products?
Height
Weight
Do you have Any current or past medical conditions?
If Yes, please specify
Are you currently on any medications?
If Yes, please list:
Have you been hospitalized or diagnosed with a critical illness in the past 10 years?
If yes, please explain
Employment & Financial Details
Do you have any existing life insurance policies?
If Yes, Please list the carrier and the coverage
Estimated Total Assets (optional)
Estimated Liabilities (optional)
Coverage Preferences
Desired Coverage Amount
If Other, please specify
Primary Purpose of Policy

Long-term protectionCash value accumulationEstate PlanningBusiness protectionOther
Do you want flexibility in premiums and coverage over time?
Beneficiary Information (Optional)
Primary Beneficiary Name

First NameLast Name
Relationship
Contingent Beneficiary (optional)

First NameLast Name
Additional Notes or Comments
Upload Photos, Files or Documents

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RMBIA Service Rep Fill out this form?
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By submitting, I acknowledge that I am requesting an insurance quote and authorize RMB Insurance Agency to obtain my credit and loss history reports.
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Personal Information