LEGACY PROTECTION FORM
Protect What Matters Most "Your Legacy"
Customer Details:
Full Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
How much can you afford to spend on life insurance monthly?
*
Have you ever been convicted of a felony?
*
If Yes, Please specify below:
Have you ever been charged for a DUI or DWI?
*
If Yes, Please specify date of charge & disposition:
Do you have a current bank account ? (Chime and Cash app UNACCEPTABLE)
*
Height
*
Example: 5”9
Weight
*
Example: 145 lbs
Describe any health issues:
*
Please be honest no discretion, medical records may be pulled if needed.
List any prescriptions you take or have taken in the past TEN years ! Enter N/A if none
*
Do you use Tobacco?
*
Yes
No
Previously, Yes
Occasionally
Are you employed?
Yes I have a job
I am a business owner
I work a job & own a business
I’m currently unemployed
If you answered yes, Enter name of employer & how long.
If you receive income, list your average monthly income amount in this box
*
Do you currently own an active life insurance policy?
*
Yes
No
I have insurance through my job
My parents have life insurance on me
Are you planning on cancelling any existing life insurance?
*
Yes
No
Do you have any investment accounts. High yield savings. Roth IRA, ect ?
*
Yes I do
No, but I’m interested
Are you planning on adding children to your policy ? If so, how many ?
*
Please List ALL children you will be adding to your policy. Enter Date of birth next to the names. You may add any dependents ( children, grandchildren, nieces and nephews )
*
Are you married?
*
Yes
No
Going through divorce
Engaged
Our Meeting will take place via Zoom call. Your video is required to be on to verify I am speaking to the right applicant. I will be sharing my screen to explain the process and safely insert your information into our company’s portal.
I understand this zoom meeting requires my video to be on and for me to be in a quiet setting so that I am able to fully understand the process
What is the name of the agent assisting you with this Process ?
*
Please add any additional comments or questions:
*
Are you interested in training to become a licensed life insurance agent ? You work at your own pace, set your own schedule & from wherever you choose. Great money to make !
I'm always ready to make extra $$$!
No, Not at time
I know someone who would be interested
Do you need any additional service?
Information Technology
Travel Business Owner
24 Hour On-Call Family Lawyer
Homeowners Insurance
Home Security System
Investments
High Yield Savings Account
Retirement Planning
Not at the moment
Please provide names and numbers of anyone you can think of that could benefit from any of the services listed above, including life insurance:
*
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Full Name
Address
Contact Number
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