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.
Email Address*
example@example.com
Social Security Number*
Gender*
Drivers License Number
Marital Status*
EMPLOYMENT INFORMATION
Company Name*
Annual Income*
Occupation*

EXISTING LIFE INSURANCE

	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

	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