Life Insurance Client Worksheet

Full Name

First NameLast Name

Social Security

Birthday

Phone number

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

What type of policy do you want?

How much death benefit are you seeking? (in USD)

Monthly budget for premium (in USD)

Parents' full names, birthdays, and passing age if deceased

Have you ever had your license suspended for a DUI?

Place of work and industry

Job Description/Position

Yearly Income (in USD)

City and State of Birthplace

Primary Doctor's Name and Address

List any current medications names and why you take in last 12 months (if applicable)

Have you been hospitalized in the last 5 years? If yes, please explain why.

Have you seen any specialists in the last 5 years?

Have you been convicted of any felonies? If yes, please explain.

Height (in feet/inches or centimeters)

Weight (in pounds or kilograms)

DL License number and expiration date

Email Address

example@example.com

Beneficiaries' names and dates of birth

Bank name- routing number and checking account number

Referral name