Life Insurance Application

Southern Legacy Partners

Life Insurance Application
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Driver's License Number
Height/ weight

HeightWeight
Gender
Marital Status
Residential Address

Street Address

Street Address Line 2
CityStateZip Code
Phone Number
Email
example@example.com
Primary beneficiary(ies)
Please provide Name, Date of Birth, and Social Security Number, and percentage.
Contingent Beneficiary(ies)
Please provide Name, Date of Birth, and Social Security Number,and the precentages.
Are you a smoker?
Have you been diagnosed with any of the following?
Hospitalizations or surgeries in the last 5 years?
If yes, explain:
Type of Coverage Interested In
Purpose of insurance
Existing Life Insurance Coverage( Carrier and Coverage amount.)
Is this policy intended to replace existing coverage
Primary Care Physician Contact

First/Last namePhone/ Address
Prescriptions
Please list any prescriptions that you are currently taking?
Nicotine/ tobacco use in the last 6 months
Alcohol Consumption in the last 6 months
Bankruptcy in the last 5 years
Felony/ Misdemeanor in the last year?
DUI/ DWI/ license revoked or suspended in the last 5 years?
By signing my name, I authorize the insurance agent to collect and use the information provided for the purpose of evaluating life insurance options and obtaining quotes. I understand that additional medical or underwriting information may be required before a policy is issued.
Should be Empty:

Southern Legacy Partners