Life Insurance Intake Form

Life Insurance Intake Form

Share your details, coverage preferences, and health/lifestyle information to help us assess your needs.
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Marital Status
Occupation
Annual Income (USD)
Insurance Interest
Which types of life insurance are you interested in?
Desired coverage amount (USD)
Primary reason for coverage
If Term Life is selected, preferred term length
Existing Coverage
Do you currently have life insurance coverage?
Insurance carrier
Policy type
Face amount (coverage amount)
How would you like this application to relate to your current coverage?
Health Information
Height (inches)
Weight (lbs)
Do you use tobacco or nicotine products?
If yes, please describe your tobacco or nicotine use
Do you have any major medical conditions?

Other
Please list and briefly describe any major medical conditions
Are you currently taking prescription medications?

Other
Please list your prescription medications and what they are for
Lifestyle Information
Have you ever been convicted of DUI or DWI?
If yes, provide the date(s) and brief details of the DUI or DWI conviction(s).
Have you ever had your driver’s license suspended, revoked, or restricted?
If yes, provide the date(s), reason, and outcome.
Have you ever been convicted of a felony?
If yes, provide the date(s), offense description, and current status.
Do you participate in any of the following hazardous activities?

Other
If you selected any hazardous activities, provide the activity name(s), frequency, and any relevant details.
Have you traveled outside your country of residence for 30 days or more in the past 5 years?
If yes, list the destination(s), dates, and purpose of travel.
Budget and Coverage Guidance
Preferred Monthly Budget
Do You Need Help Determining Coverage Amount?
Budget and Coverage Guidance Notes
Contact Preferences and Consent
Preferred Contact Method

Other
Best Time to Contact

Hour Minutes

AM/PM Option
Consents to be Contacted
Acknowledgment
Electronic Signature
Date

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

Life Insurance Intake Form

Insurance Interest

Existing Coverage

Health Information

Lifestyle Information

Budget and Coverage Guidance

Contact Preferences and Consent