Information Request Form

Name

First NameLast Name

E-mail

example@example.com

Phone Number

Area CodePhone Number

State of Residence

Date of Birth

Date

Height

For Example: 5'5"

Weight

For Example: 140lbs

What's your gender?

Which type of life insurance best fits your needs?

What's the primary reason you're considering life insurance? (you may choose several options)

How much coverage are you interested in? (For Example- $50,000, $100,000, $1 million)

What do you do for work?

What's your monthly budget?

Type a question

Are you a smoker?

Do you have any health conditions?

Please list any past or current diagnoses, along with the year you were diagnosed and current status (i.e. high blood pressure- diagnosed 2010- controlled with medication). This helps us to determine which carrier would be suitable in offering you the best coverage and rate. Please indicate N/A if not applicable.

Are you currently taking any medications?

Please list the name of each medication, what you're taking it for, and how long you've been taking it (i.e. Albuterol- asthma- 5 years). This aids us in finding the most accurate rate for you. Please indicate N/A if not applicable.

Do you have life insurance through work?

If you have insurance through your job, how much is the coverage and what's the monthly payment amount?

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 20 year), how much is the coverage, and what's the monthly payment amount?

In the past five years, have you filed for bankruptcy?

In the past five years, have you gotten any DUI's?

In the past ten years, have you been convicted of a felony?

Write any further comments or questions below:

Life Insurance Questionnaire