Client Qualification Form

Client Qualification Form

By completing this brief form you’ll assist me in gathering the necessary information I need to provide accurate and affordable quotes for your needs. Please be as honest as possible so I am able to fit you with the correct carrier for your needs.
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Birth Date*

MonthDayYear
What type of policy are you looking for or would like information on?
Select all that are applicable
Height*
example: 6'1''
Weight*
example: 110lbs
Any tobacco use?
If yes, please specify. Ex. Cigarette, Vape, Chewing Tobacco
List any health issues from past 10 years (high blood pressure, cancer, diabetes, surgeries, stroke, high cholesterol, accidents, any hospital stays, etc.)*
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 determine which carrier will offer you the best coverage and rate.
List routines medications you take or have been prescribed in the past 10 years *
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 to find the most accurate rate for you as every carrier has different guidelines.
What is your WHY? Select all that apply*

Pay off my mortgage for my family in the event something happened to meProtect my family’s income if something happens to me unexpectedlyLeave money behind for my loved ones (Final Expense or Legacy Planning)Build wealth. Build cash value and savings fundRetirement income planningA benefit paid to my family in the event I pass from a non medical accidental deathPlan for my children’s education or futureEliminate my debt and become my own bank
In the past 10 years have you had any DUIs OR suspended license? Please list when and why.
In the past 10 years have you filed for bankruptcy?*
In the past 10 years have you been convicted of a felony?*
Do you have a group life insurance through work?

YesNo
If you have insurance through work, how much is the coverage and what's the monthly payment amount?
Ex: 300k - $75 a month
Do you have life insurance outside of work?

YesNo
If yes, list what you know of the carrier, policy type, coverage amount and monthly payment
Ex: Mutual of Omaha, whole life, 300k, $75 (note: these are factual numbers and not reflective of a real policy)
If interested in Mortgage Protection please provide mortgage lender, amount, and years left on loan for accurate quoting
Ex: Bank of America, $340k, 25yrs
If you have a budget in mind please list below. This will help me determine how much coverage you can get!
Please add any additional comments or questions:
Should be Empty: