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
MaleFemale
Marital Status *
Residential Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
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.
YesNo
Heart DiseaseDiabetesCancerHigh Blood PressureHigh CholesterolNone
YesNo
If yes, explain:
Term LifeWhole LifeFinal Expense
income replacementmortgage protectionFinal expense / burial costs (funeral, medical bills)Business protection (key person insurance, buy-sell agreements)Retirement planningDebt repaymentEstate planning / wealth transferEducation funding
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.

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Southern Legacy Partners