Clone of Pre-Screening Life Insurance Application

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Congratulations on taking the first step to securing you and your family's future! Please complete all fields as this information is needed to complete your application. Please be sure to have the following information available: SSN, bank routing and account number, and other insurance policy information. This form must be completed for each person 18+ receiving a quote.
Email*
example@example.com
Name *

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Please list the full name and social security numbers for each person over the age of 18 years old.*
What is your address (include apartment number)?*
Date of Birth*

MonthDayYear
Date
What is your city, state and zip code?*
What is your birth country (e.g., USA)?*
Please list your address(es) for the past five (5) years. Include the street address, city, state, zip code, and date range of living at the address (e.g., March 2020-present). *
Age?
Height (i.e., 5'7)*
Weight (i.e., 180)*
TobaccoNon-tobaccoMarijuanaVape
NoneWhole LifeTermWhole Life and Term
What is the name of the company that you have coverage with, what is the coverage amount and if available what is the policy number?*
Do you have ANY medical diagnosis? If so, list every diagnosis below and at what age you were diagnosed. *
Do you have ANY Mental Health diagnosis? If so, list every diagnosis below and at what age you were diagnosed.*
Have you been prescribed ANY medications within the past 10 years? If so, list EVERY medication, dosage, and frequency of taking the medication below. Include all medications whether you are taking them or not. *
Have you been hospitalized in the past 12 months? If so, what was the cause and dates of the hospitalization?*
YesNo
YesNo
Do you have a state drivers license? If so, include the state and driver's license number below. *
If you do not have a state driver's license why? If suspended, what is the reason for the suspension?*
If you do not have a state driver's license, do you have a state ID? If so, include the state and ID number below. If not, why?*
Do you have a high-risk job (e.g., military, law enforcement, occupational travel, etc.)? If so, what do you do?*
What is the name of your current employer?*
What is your occupation?*
What is your annual salary?*
YesNo
YesNo
TermWhole LifeUniversal LifeFinal ExpenseI am unsure and need guidance.
What is your monthly budget for your policy?*
How much life insurance coverage would you like for us to quote?*
Who would you like listed as your primary beneficiary? This person will get the death proceeds. Please include their date of birth. List the date format as MM/DD/YY. For example, if the date is December 5, 2023, list it below as 12/05/23.*
What is your relationship to the primary beneficiary? Acceptable primary beneficiary relationships include: spouse/fiancée/domestic partner, parent, adult child, siblings, grandparents, grandchildren, close relatives by marriage (i.e., in-laws and step-relations), ex-spouse, Life Insurance Trust, Business or Business Partner, or estate.*
Who would you like listed as your contingent beneficiary? This person will get the death proceeds if you outlive your primary beneficiary. Please include their date of birth. List the date format as MM/DD/YY. For example, if the date is December 5, 2023, list it below as 12/05/23.*
What is your relationship to the contingent beneficiary? Acceptable contingent beneficiary relationships include: spouse/fiancée/domestic partner, parent, adult child, siblings, grandparents, grandchildren, close relatives by marriage (i.e., in-laws and step-relations), ex-spouse, Life Insurance Trust, Business or Business Partner, or estate, other distant relatives (Aunts, Uncles, Niece, Nephew, Cousins, etc.), or Friends.*
What is the name of your financial institution (e.g., Bank of America)?*
CheckingSavings
What is your routing number?*
What is your bank account number?*
What day of the month would you like the INITIAL premium drafted from your bank account? (List the date format as MM/DD/YY. For example, if the date is December 5, 2023, list it below as 12/05/23.) *The initial draft must be within 30 calendar days.**
What day of the month would you like the RECURRING premium drafted from your bank account each month? (Simply list the day of the month below. For Example: 1st, 8th, 15th, 20th, etc.)*
Are there any children under the age of 18 you would like to cover? If so, please provide their names and date of birth.*
Who do you know who might be interested in a policy or joining our team? Please provide their first and last name, phone number, and email address. You may also share my contact information by introducing me in a group text.
Thank You!
We appreciate your time and look forward to servicing you and your family! Looking forward to speaking with you soon! Let's stay connected! Maya Hunter
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