Term Intake Form

Term Insurance Intake Form
Use the information below to complete a drop ticket for term life insurance at www.mysynchronizedashboard.com, Synchronize Drop Ticket Term. First-time users read the How To Get Started section on the Synchronize Drop Ticket Term landing page.
Advisor Name*
Advisor Phone*
Broker-Dealer /Firm Name/Affiliation*
Advisor Email
example@example.com
Date This Intake Form Was Completed

MonthDayYear
Date
Is there a secondary advisor/agent on this case?

YesNo
Secondary Advisor Name
What is the compensation split?
Client Information

All Fields are Required
Insured Name*
State of Residence*
Date of Birth*
Gender*
Marital Status
Client Birth Country / State*
Social Security #*
Address*
City*
State*
Zip*
Primary Phone*
Driver's License State*
Driver's License #*
Driver's Licenses Exp. Date*

MonthDayYear
Date
Insured Email Address*
example@example.com
Tobacco Usage*

NoYes
Yes (Indicate type of tobacco and last date of use)

MonthDayYear
Date
Has the proposed insured ever been treated for the following? Cancer, Heart Disease, Stroke (if yes, indicate date of diagnosis)

YesNo
Best Time to Contact Client

AMPM
Preferred phone number for contact
Rate Class, Carrier and Product Information
Rate Class*

Preferred BestPreferredStandard PlusStandard Non-TobaccoStandard TobaccoPreferred TobaccoOther
Type of Insurance: (Term Length)*
Face Amount*
Carrier*
Product Name
Premium Mode*

AnnualSemi-AnnualQuarterlyMonthly (EFT)
Premium Amount
Employment and Income Information
Is the Proposed Insured Currently Employed?*

YesNo
Employer*
Job Title*
Annual Income*
Estimated Total Assets
Estimated Total Liabilities
Net Worth*
Owner Information
If Insured is NOT owner (The following is mandatory or needed):
Owner is a

PersonTrustCorporationOther
Owner Name
Owner Email Address
Social Security # / Tax ID
Address

Address

Street Address Line 2

CityState

Zip
Relationship to Proposed Insured
Owner DOB or Trust Date

MonthDayYear
Date
Beneficiary Information
Primary Beneficiary Name*
SSN or TAX ID*
Relationship*
Percent*
Additional Beneficiary Name
Beneficiary Type

PrimaryContingent
SSN or TAX ID
Relationship
Additional Beneficiary Name
Beneficiary Type

PrimaryContingent
SSN or TAX ID
Relationship
Replacement Information

If applicable
Does the client currently own any life insurance?*

YesNo
If Yes, Is this policy replacing any existing coverage?*

YesNo
If Yes, Indicate Reason for Replacement
If there is existing coverage, please provide the following:
Insurance Company:
Death Benefit:
Policy Number:
Issue Date:
Additional Information
What is the purpose of this insurance?: i.e. income replacement, etc*
Source of Funds for Premium (please be specific)*
Rider(s)

Waiver of PremiumOther
Has the client ever been declined, rated or postponed for life of health insurance?*

YesNo
How long have you known the insured?*
Did you meet with the client personally to complete this form?

YesNo
Was an illustration presented to the insured?

YesNo
Advisor Information
(SSN is required for advisors submitting their first application through the term-intake process and will be kept confidential under the Synchronize Privacy Policy practices)
Advisor Social Security Number
Advisor Remarks
Synchronize was formed by Lockton Affinity, an affiliate of Lockton Companies, the world’s largest privately held, independent insurance broker. Synchronize brings together four companies that specialize in the financial advisor industry – Lockton Affinity, SBG, Freedom Partners, and The BluePrint Insurance Services.

Synchronize Insurance Services are administered by Lockton Affinity, LLC d/b/a Lockton Affinity Insurance Brokers LLC in California #0795478. Coverage is subject to actual policy terms and conditions. Policy benefits are the sole responsibility of the issuing insurance company.
Should be Empty:

Term Insurance Intake Form

Client Information

Rate Class, Carrier and Product Information

Employment and Income Information

Owner Information

Beneficiary Information

Replacement Information

Additional Information

Advisor Information