LIFE INSURANCE Fact-Finder (Beneficial Wealth)

LIFE INSURANCE Fact-Finder (Beneficial Wealth)
CONFIDENTIAL QUESTIONNAIRE
This form is for informational purposes only and does not constitute an application for insurance. No coverage will be provided unless and until a signed, completed application is submitted and approved.
PERSONAL INFORMATION
Full Legal Name*
Date of Birth*

MonthDayYear
Date
Place of Birth*
Home Address
Cellphone*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Social Security Number*
Gender*
Drivers License Number
Marital Status*
EMPLOYMENT INFORMATION
Company Name*
Annual Income*
Occupation*

EXISTING LIFE INSURANCE

Rows	Company	Policy	Issue Date	Face Amount	Owner
1
2

MEDICAL HISTORY

Please list all physicians visited in the last 5 years.
Physician's Name*
Date Last Seen*

MonthDayYear
Approximate
Address
Physician’s Name
Date Last Seen

MonthDayYear
Approximate
Address
Physician’s Name
Date Last Seen

MonthDayYear
Approximate
Address

BENEFICIARY INFORMATION

Rows	Beneficiary Name	Beneficiary Relationship	Share	Date of Birth	Primary/Contingent
1
2
3

LIFE INSURANCE Fact-Finder
Plan of Insurance requested*

TermPermanentUnsure
Years*
Primary goal to build cash or low premiums*
Death Benefit Amount
Expected Premium
Premium Frequency

AnnualSemi-annQuarterlyMonthly
# of years:*
To Age:*
$*
Proposed Insured's information
Nicotine or Marijuana use:*

NoneCigarettes, Cigars, Pipe, Dip, Chew, Nicotine, Gum, OtherMarijuana
If yes, frequency and type*
Former Nicotine Use
List each type, quantity and frequency used, and date of last use.
Height*
feet
Weight*
pounds
Latest BP reading

ex. 120/80
Latest Cholesterol
mg
Latest cholesterol/HDL ratio
Are you currently taking any medication for BP?*

NoYes
Name of medication/s*
Have you had any of the following motor-vehicle-related incidents in the past 10 years?

NoMoving violationReckless drivingDWI or DUILicense suspension or revokedOther
Are you currently taking any medication for cholesterol?*

NoYes
Name of medication/s*
Provide dates, details
Have you ever had, been told you had, or been treated for any of the conditions listed? If yes, check all that apply:*

None belowAcquired immune deficiency syndrome or ARC (AIDS-related complex)Alcohol abuseAlzheimer's/dementia/cognitive impairmentAsthmaCancerCirrhosisCOPDCoronary artery or cerebrovascular diseaseCrohn's diseaseDepression/anxietyDiabetes Type 1Diabetes Type 2Drug abuseEpilepsyHeart murmur/valve diseaseHepatitisInternal organ transplantIrregular heartbeat/palpitationsKidney diseaseLupusMultiple sclerosisPeripheral vascular diseaseRheumatoid arthritisSleep apneaStrokeOther
List dates, diagnosis, details, treatment for any condition checked on previous page
If diabetes

T1T2
Age at Onset*
A1C score*
Please provide details.*
Prescription Medications: Please list any prescription medications, dosage, and purpose if not listed previously.*
If no drugs put "No Drugs"
Family History: [Family history is a consideration for each rate class]
To your knowledge, is there any family history (parent or siblings) of death due to heart disease or cancer under age 60?*

NoYes
Provide details*
Aviation/Avocation
In the past 5 years have you or do you intend to participare in any of the activities listed?*

NoneFlyingRacingSky DivingScuba Diving
Should be Empty:

LIFE INSURANCE Fact-Finder (Beneficial Wealth)

CONFIDENTIAL QUESTIONNAIRE

PERSONAL INFORMATION

EMPLOYMENT INFORMATION

MEDICAL HISTORY

LIFE INSURANCE Fact-Finder

Proposed Insured's information

List dates, diagnosis, details, treatment for any condition checked on previous page

Family History: [Family history is a consideration for each rate class]

Aviation/Avocation