Yellow Rose Agency Intake Form

YELLOW ROSE AGENCY
LIFE INSURANCE CLIENT INTAKE FORM

Helping us match you with the right policy and provider.

Office: (806) 355-7838. Email: staff@yralife.com Website: www.yralife.com
Section 1: Contact Information
Name

First NameLast Name
Date fo Birth

MonthDayYear
Date
Height
Weight
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email

Confirmation Emailexample@example.com
Gender
State of Residence
Agent
Section 2: Coverage Amount and Type
What is your main reason for purchasing life insurance?
Desired Coverage Amount
Desired Monthly Budget
Preferred Policy Type
Desired Length of Coverage (If Term)
Do you currently have life Insurance?
If you currently have a life policy please list the type and how much coverage
Section 3: Health & Medical History
Do you currently take any prescription medication?
Explain if yes
Any major medical condition (past or present)?

Other
Tobacco or Nicotine use in the last 12 months?
Have you been declined or rated for life insurance before?
Explain if yes
Section 4: Lifestyle & Risk Factors
Do you have any history of DUI, felony, or license suspension?
Details if yes
Use this space for any relevant details or considerations that you would like your Agent to know:
Important Notice:The life insurance quote provided in connection with this intake form is for illustrative purposes only and does not constitute a binding offer or guarantee of coverage. Final premium rates are subject to underwriting review and approval, which will take into consideration various factors including, but not limited to, age, health status, medical history, lifestyle, and occupational risk. By submitting this form, you acknowledge and understand that the initial quote may be adjusted based on the outcome of the underwriting process.
Signature
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YELLOW ROSE AGENCY

Section 1: Contact Information

Section 2: Coverage Amount and Type

Section 3: Health & Medical History

Section 4: Lifestyle & Risk Factors