Insurance Intake Form

Insurance Intake Form

Complete this insurance intake form to provide applicant, beneficiary, payment, medical, and history information. Please follow the exact order and structure of the PDF. Sensitive fields are grouped and labeled accordingly.
Type of Insurance
Term Life provides coverage for a chosen period; Whole Life provides permanent coverage with guaranteed cash value subject to policy terms; IUL is permanent life coverage with cash value tied to an index subject to caps, participation rates, costs, and policy terms; Final Expense is typically smaller whole life coverage intended to help with end-of-life expenses; Children’s Whole Life provides permanent coverage for a child with cash value subject to policy terms.
Applicant Information
First Name
Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
Zip Code
Gender
Years of Residence
Email
example@example.com
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Yes, email me policy service reminders and periodic coverage review check-ins from The Healthy Ledger.
Yes, I would like to receive occasional email birthday greetings, tax tips, tax deadline reminders, and financial education from The Healthy Ledger. I can unsubscribe at any time.
Budget

Optional premium comfort range
Actual premiums depend on the coverage selected and the underwriting review. If you’re not sure yet, you can choose that option.
What is your comfortable monthly budget for insurance?
Citizen?
City of Birth
Country of Birth
Height (ft/in)
Weight
Annual Income
Net Worth
Marital Status
Driver’s License & Driving History
Does the insured have a driver’s license?
Driver’s License Issue State
Driver’s License Number
Driver’s License Issue Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Driver’s License Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
History of DUI or driving while impaired
History of reckless driving
Upload Driver’s License

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Parents’ Status
Is your dad still living?
Dad’s Age, first and last name (if not living age of death)
Is your mom still living?
Mom’s Age, first and last name (if not living age of death)
Employment Information
Is the insured currently employed?
Type of Business
Current Employer’s Name
Occupation Title
Employer Address
Employer City
Employer State
Employer Zip
Employment Duration
Tobacco Information
Have you ever used tobacco or nicotine in any form?
Source of Funds

Other
Beneficiary Information
Primary Beneficiary Name

First NameLast Name
Primary Beneficiary Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Beneficiary Relationship to Insured
Primary Beneficiary Gender
Primary Beneficiary Percentage Payable
Secondary Beneficiary Name

First NameLast Name
Secondary Beneficiary Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Secondary Beneficiary Relationship to Insured
Secondary Beneficiary Gender
Secondary Beneficiary Percentage Payable
Primary Beneficiary Tax Identification Number
Secondary Beneficiary Tax Identification Number
Beneficiary Type
Beneficiary Allocation Note
Existing Insurance
Existing life insurance or annuity coverage with this or any other company
Applied for or contemplating other life insurance in the past 6 months
Premium Payment / Banking
Bank Name
Account Number
Routing Number
Account Type
Bank Address
Bank City
Bank State
Upload Banking Document

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Primary Physician
Primary Physician Name

First NameLast Name
Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Physician Address
City
State
Date Last Seen

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Visit
Medication Information
Current Medications
Dosage / Frequency
Prescribing Physician / Clinic
Upload Medication List

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Medical History
Heart disease and related conditions
Stroke/TIA/carotid/peripheral vascular disease/aneurysm/other blood vessel disorders
Cancer/tumor/abnormal growth/mass/melanoma/lymphoma/leukemia
Anemia/clotting disorder/other blood disorders
Immune system disorders (excluding HIV/AIDS/ARC)
HIV/ARC/AIDS or related conditions
(Last 10 years) High blood pressure
(Last 10 years) Diabetes or abnormal blood sugar
(Last 10 years) Depression/anxiety/ADHD/bipolar/schizophrenia/PTSD/psychiatric treatment
(Last 10 years) Asthma/chronic bronchitis/COPD/emphysema/sleep apnea/tuberculosis/other lung disorders
(Last 10 years) GI bleeding/ulcers/Crohn’s/Barrett’s/ulcerative colitis/hepatitis/cirrhosis/colon polyps/other GI or liver/pancreas disorders
(Last 10 years) Kidney/urinary bladder/blood in urine/protein in urine/prostate/ovaries/uterus/cervix disorders including abnormal Pap smear
Thyroid/pituitary/parathyroid/adrenal gland disorders
Arthritis/fibromyalgia/chronic pain/back pain/joint or muscle conditions
Lupus/scleroderma/connective tissue disease/autoimmune disorders
Seizures/epilepsy/tremors/MS/paralysis/Alzheimer’s/dementia/Parkinson’s/blindness/other brain or nervous system disorders
Aggression/ODD/conduct disorder
Any other psychiatric impairment/condition
(Last 5 years) Psychiatric hospitalization or inpatient treatment or advised to be hospitalized
General Information
Moving violations, DUI, or suspended license in the last 5 years?
Any felony or misdemeanor conviction, charge, parole, or probation in the last 10 years?
Any bankruptcy proceedings not discharged?
Bankruptcy details (type and date discharged)
Participation in hazardous sports or activities?
Participation in aviation other than as a fare-paying passenger?
Was any cash incentive or other consideration offered as an inducement to apply?
Have there been any discussions about sale or transfer of the policy to an unrelated third party?
Signature Section
Signature
Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Insurance Intake Form

Applicant Information

Budget

Driver’s License & Driving History

Parents’ Status

Employment Information

Tobacco Information

Beneficiary Information

Existing Insurance

Premium Payment / Banking

Primary Physician

Medication Information

Medical History

General Information

Signature Section