Life Insurance Questionnaire

Life Insurance Questionnaire

By completing this brief form, you'll help your agent, Anthony Johnson, 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.
Name*

First NameMiddle NameLast Name
Phone Number*
Please enter a valid 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?*

MaleFemale
Which type of Life Insurance are you interested in?**
What's your main reason for getting life insurance? ( you may select multiple options)*

Protect my family's income incase something happens to me unexpectedlyBuild cash value and savings fundFund retirement income portfolioMortgage Protection (coverage for mortgage/debt)Leave a cash gift for the family when you passCover 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 1st business)Become my own bank and build generation wealth (Cash value policy; IUL)Not sure need advise or guidance
How much coverage are you looking for? (Ex: $25,000, $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 (income, mortgage, or final expenses.)
What's your monthly budget?*
Do you use tobacco?*

YesNo
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 life insurance through work?*

YesNo
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?
Do you have life insurance outside of work?*

YesNo
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?*

YesNo
In the past 5 years, have you filed for bankruptcy?*

YesNo
In the past 10 years, have you been convicted of a felony?*

YesNo
Please add any additional comments or questions:
Should be Empty: