Carter Financial Client Information Form

Carter Financial Client Information

Please complete the questionnaire below so that we can begin work on your application.
Full Name of Proposed Insured*

First NameMiddle NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Work Phone Number*

Area CodePhone Number
Email Address*
example@example.com
Date of Birth*

MonthDayYear
Date
Social Security Number*
Place of Birth*
State & County
Driver's License Number
Driver's License Issue State
Upload an image of the FRONT of your Government Issued I.D.

Browse Files

Cancelof
Upload an image of the BACK of your Government Issued I.D.

Browse Files
Driver's License, Passport, etc. Cancelof
Are you a citizen of the USA?*

YesNo
What is your height?*
What is your weight?*
List your employer & time employed*
What is your occupation w/specific duties?*
What is your annual Income?*
What are your annual household expenses?*
What is your Net Worth?*
List your primary beneficiaries
List your contingent beneficiaries
Do you have existing life insurance or annuities?*

YesNo
List your existing Life Insurance and/or Annuity Company, Policy Number, Issue Date, Coverage Amount
Do you have any health issues or pre-existing conditions?*

YesNo
List any health issues or pre-existing conditions
Are you taking prescription medicine?*

YesNo
List any prescription medicine that has been prescribed to you
Do you have a primary physician who maintains your health records?*

YesNo
Physician Name

First NameLast Name
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Phone Number

Area CodePhone Number
What was the date of your last Physician appointment?
Month & Year
What was the reason for your last Physician appointment and what was the outcome?
e.g. Check-up. Normal results
Have you used any type of products containing tobacco or nicotine within the last five years?*

YesNo
Provide details on tobacco or nicotine usage in the last five years (type, frequency, date of last use)
e.g. cigarettes, 2 per day, 10/1/19
Have you been convicted or plead guilty of moving vehicle violations or DUI in the last 5 years?*

YesNo
Provide details on moving vehicle violations or DUI in the last 5 years
e.g. Speeding, 55 in a 35, 10/1/2019
Have you been convicted of a felony or misdemeanor?*

YesNo
Provide details on any felony or misdemeanor convictions
Have you been or are you currently involved in any bankruptcy proceedings that have not been discharged?*

YesNo
Provide details on any bankruptcy proceedings including discharge date
Do you participate in racing, scuba diving, aerial sports, mountain climbing, BASE or bungee jumping or cave exploration?*

YesNo
Provide details on dangerous activities you participate in.
Do you participate in aviation activity other than as a fare paying passenger?*

YesNo
Provide details on aviation activity you participate in other than as a fare paying customer
Is your Father living?*

YesNo
What age is your Father? (Note: List date of death and cause if applicable)*
Is your Mother living?*

YesNo
What age is your Mother? (Note: List date of death and cause if applicable)*
Has a parent or sibling been diagnosed or treated by a health professional for cancer, heart disease, Huntington's Disease or polycystic kidney disease?*

YesNo
Provide details on parents or siblings with a diagnosis or treatment for cancer, heart disease, Huntington's Disease or polycystic kidney disease
e.g. Check-up. Normal results
Who is your Advisor at Carter Financial?*
Who is your Advisor at Carter Financial?*
Last Updated: 5/1/19

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