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.
Email*

Confirmation Emailexample@example.com
Gender*

MaleFemaleN/A
State of Residence *
Agent*
Section 2: Coverage Amount and Type
What is your main reason for purchasing life insurance?*

Family ProtectionIncome ReplacementEstate Planing
Desired Coverage Amount*
Desired Monthly Budget*
Preferred Policy Type*

TermWhole LifeIUL (Index Universal Life)Final ExpenseI'm Not Sure
Desired Length of Coverage (If Term)

10 Years15 Years20 Years30 Years
Do you currently have life Insurance?*

YesNo
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?*

Yes (If yes, please list medication and condition )No
Explain if yes
Any major medical condition (past or present)?*

HeartCancerDiabetesAsthmaMental HealthNoneOther
Tobacco or Nicotine use in the last 12 months?*

YesNo
Have you been declined or rated for life insurance before?*

YesNo
Explain if yes
Section 4: Lifestyle & Risk Factors
Do you have any history of DUI, felony, or license suspension?*

Yes (Details if Yes)No
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