Legacy Life-Insurance Questionnaire

Legacy Life-Insurance Questionnaire

Thank you for taking a moment to complete the Legacy Life Insurance questionnaire. I truly believe planning ahead is an act of love and stewardship, and this is an important step in protecting the people God has placed in your care. Your answers will help me understand your family’s needs so I can guide you toward coverage that brings peace of mind, security, and lasting protection. There’s no pressure—just honesty and intention as we work together to build a legacy that reflects your values and your love for family. Take your time and answer as accurately as possible—this is about building something meaningful and intentional for your future.
Tell Us About You

All information is kept in strict confidence.
Full Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Marital status
Social Security Number
Driver’s License Number
State:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
E-mail
example@example.com
Occupation
When is the best time to contact you?
Best way Contact
Annual Income
Height
example: 6'1''
Weight
example: 110lbs
Children
Grand-Children
Which Life Plan?
How much life insurance do you want us to quote?
Describe any health issues?
Spouse information
Full Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Marital status
Social Security Number
Driver’s License Number
State:
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
E-mail
example@example.com
Occupation
Annual Income
Existing Life Insurance?
Total life insurance on you right now?
Are you planning on cancelling any existing life insurance?
Do you have group life insurance through work?
Who will be responsible for paying on the policy?

Other
Coverage Information
Type of Coverage Requested
What type of life insurance are you interested in
If applying for Term Life Insurance, what term length would you like
Desired Coverage Amount

Other
Purpose of Coverage

Other
Do you currently have life insurance?
Insurance Company
Coverage Amount
Policy Type
Year Issued
Are you replacing an existing policy?
Beneficiary Information
Primary Beneficiary
Full Name

First NameLast Name
Relationship to You
Date of Birth

MonthDayYear
Date
Percentage of Benefit
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contingent Beneficiary
Full Name

First NameLast Name
Relationship to You
Date of Birth

MonthDayYear
Date
Percentage of Benefit
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are any beneficiaries minors?
If yes, have you assigned a guardian or trustee?
Military Information
Have you ever served in the military?
Branch of Service:
Current Status:
Have you been deployed within the last 5 years?
Tobacco / Nicotine Questions
Are you:
Primary Care Physician:
Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like to add any riders?

Other
Do you certify all information provided is true and complete?
Estate Planning & Family Protection
Would you like to learn more about wills and trusts through LegalShield to help protect your family and assets?
Are you interested in information
Please add any additional comments or questions:
Signature
Date

MonthDayYear
Date
Should be Empty:

Legacy Life-Insurance Questionnaire

Tell Us About You

Spouse information

Existing Life Insurance?

Coverage Information

Beneficiary Information

Primary Beneficiary

Contingent Beneficiary

Military Information

Tobacco / Nicotine Questions

Primary Care Physician:

Estate Planning & Family Protection