Key Person Protection — Client Application & Document Pack

Key Person Protection — Client Application & Document Pack

Confidential client intake completed by the presenting agent together with the client company to open a key person insurance file for keymaninsurance.com.
Presenting Agent
Agent Full Name

First NameMiddle NameLast Name
Agent Phone
Please enter a valid phone number.Format: (000) 000-0000.
Agent Email
example@example.com
Client Company
Company legal name
Principal business activity / industry
Year incorporated
Registered office address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Main banker
Company email
example@example.com
Company phone
Please enter a valid phone number.Format: (000) 000-0000.
Key Lives to Insure
Key Life 1 Full Name

First NameMiddle NameLast Name
Key Life 1 Role / Title
Key Life 1 Date of Birth

MonthDayYear
Date
Key Life 1 Smoker Status
Key Life 1 Monthly Salary + Benefits (TT$)
Key Life 1 Medical History Headlines
Key Life 2 Full Name

First NameMiddle NameLast Name
Key Life 2 Role / Title
Key Life 2 Date of Birth

MonthDayYear
Date
Key Life 2 Smoker Status
Key Life 2 Monthly Salary + Benefits (TT$)
Key Life 2 Medical History Headlines
Financial Snapshot
Revenue (TT$)
Gross Profit (TT$)
Pre-tax Profit (TT$)
Shareholders' Equity / Book Value (TT$)
Total Bank Facilities, Loans and Overdrafts (TT$)
Audit Status
Document Uploads
Financial statements for the last 3 years (PDF preferred)

Cancelof
Shareholder register extract with shareholder ages

Cancelof
Bank facility letters for all loans and overdrafts

Cancelof
Existing insurance policies or shareholders' agreement

Cancelof
Notes and Consent
Notes for the specialist
Consent
Should be Empty:

Key Person Protection — Client Application & Document Pack

Presenting Agent

Client Company

Key Lives to Insure

Financial Snapshot

Document Uploads

Notes and Consent