Logistical Data Form

1
Please Select the Application* This field is required.
Life Insurance
Annuity
2
Full Name* This field is required.
First Name
Middle Name
Last Name
Suffix
3
Marital Status* This field is required.
Married
Single
Divorced
Separated
4
Spouse Full Name* This field is required.
First Name
Middle Name
Last Name
Suffix
5
Gender* This field is required.
Male
Female
6
Spouse Gender* This field is required.
Male
Female
7
Date of Birth
Date
Month
Day
Year
8
Spouse Date of Birth
Date
Month
Day
Year
9
Social Security Number
10
Spouse Social Security Number
11
US Citizen* This field is required.
Yes
No
12
Spouse US Citizen* This field is required.
Yes
No
13
Smoker* This field is required.
Yes
No
14
Spouse Smoker* This field is required.
Yes
No
15
Visa Type & Exp Date
16
Spouse Visa Type & Exp Date
17
State | Driver License Number | Exp. Date
18
Spouse State | Driver License Number | Exp. Date
19
Approximate Weight
20
Height
21
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
22
Years at Residence* This field is required.
23
Phone Number* This field is required.
24
E-mail* This field is required.
25
Spouse E-mail* This field is required.
example@example.com
26
Are you Retired?* This field is required.
Yes
No
27
Spouse Retired?* This field is required.
Yes
No
28
Employer Name | Address | City, State, Zip Code* This field is required.
29
Spouse Employer Name | Address | City, State, Zip Code* This field is required.
30
Occupation* This field is required.
31
Spouse Occupation* This field is required.
32
Employer Phone Number* This field is required.
Example 410-555-1212
33
Spouse Employer Phone Number* This field is required.
Example 410-555-1212
34
How Long at Current Job* This field is required.
35
How Long Has the Spouse Been at Current Job* This field is required.
36
Household Net Worth* This field is required.Home, Cars, Jewelry, Bank Accounts, etc.
37
Annual Income* This field is required.
38
Spouse Annual Income* This field is required.
39
Source of Funds* This field is required.Payroll, 401k, Inheritance
40
Spouse Source of Funds* This field is required.Payroll, 401k, Inheritance
41
Is the Insured and the Owner The Same Person?* This field is required.
Yes
No
42
Full Name* This field is required.
First Name
Middle Name
Last Name
Suffix
43
Gender* This field is required.
Male
Female
44
Date of Birth* This field is required.
Date
Month
Day
Year
45
Social Security Number
i.e. 111-11-1111
46
Relationship to the Insured* This field is required.
47
Marital Status* This field is required.
Married
Single
Divorced
Separated
48
US Citizen* This field is required.
Yes
No
49
Visa Type & Exp Date
50
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
51
Years at Residence* This field is required.
52
Annual Income* This field is required.
53
Net Worth* This field is required.Home, Cars, Jewelry, Bank Accounts, etc.
54
Source of FundsPayroll, 401k, Inheritance
55
State | Driver License Number | Exp. Date
56
Phone Number
57
E-mail* This field is required.
example@example.com
58
Do you have an existing Insurance Policy (Outside of Employment)* This field is required.
YESNO
59
Insurance Company* This field is required.
60
Policy Number
61
Face Value* This field is required.
62
Type Of Insurance* This field is required.
Term Life
Whole Life
Universal Life (IUL)
63
Replacing Current Policy* This field is required.
Yes
No
64
1035 Exchange* This field is required.Money from Another Policy
Yes
No
Other
65
Issue Date* This field is required.
Example 01-01-24
66
How Many Beneficiaries* This field is required.
1
2
3
4
5
67
Name* This field is required.
First Name
Last Name
68
Date of Birth* This field is required.
Date
Month
Day
Year
69
Social Security Number
70
Percentage Allocated to Beneficiaries* This field is required.Example: 100%, 50%, etc.
71
Relationship* This field is required.
72
Phone Number* This field is required.
i.e. 410-555-1212
73
Email* This field is required.
Example: john@example.com
74
Name* This field is required.
First Name
Last Name
75
Date of Birth* This field is required.
Date
Month
Day
Year
76
Social Security Number111-11-1111
77
Percentage Allocated to Beneficiaries* This field is required.Example: 100%, 50%, etc.
78
Relationship* This field is required.
79
Phone Number* This field is required.410-555-1212
80
Email* This field is required.
Example: john@example.com
81
If you have more than 2 Beneficiaries, Please List Here Using Previous Information
82
In past 5 years have you ever had your Driver’s License REVOKED:* This field is required.
Yes
No
83
If yes, provide details:
84
In past 5 years have you ever had your Driver’s License SUSPENDED* This field is required.
Yes
No
Other
85
If yes, provide details:
86
Convicted of Felony, Misdemeanor, or Been on Probation or Parole in Past 10 Years?* This field is required.
Yes
No
Other
87
If yes, provide details:
88
Have you consulted a member of the medical profession for, been treated for, or been diagnosed as having:
89
Seizure, stroke, epilepsy, or any disease or abnormality of the brain?* This field is required.
Yes
No
90
High blood pressure, heart attack, heart murmur or any disease or abnormality of the heart, blood vessels, or blood?* This field is required.
Yes
No
91
Asthma, chronic bronchitis, pneumonia, tuberculosis or any disease or abnormality of the lungs, or respiratory system?* This field is required.
Yes
No
92
Arthritis, gout, back trouble or any disease or abnormality of the joints, muscles, or bones?* This field is required.
Yes
No
93
Diabetes or any disease or abnormality of the thyroid, adrenal, pituitary, or other glands?* This field is required.
Yes
No
94
Cancer, tumor, polyp or cyst?* This field is required.
Yes
No
95
Anxiety, depression, suicide attempt or any psychiatric, mental or emotional condition or disorder?* This field is required.
Yes
No
96
Within the past 10 years:
97
Diagnosed or treated for Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?* This field is required.
Yes
No
98
Have you ever been treated or counseled or been advised to seek treatment or counseling for the use of alcohol, drugs, or other substance or joined an organization for alcohol or drug dependence or abuse?* This field is required.
Yes
No
99
Have you been advised to have any surgery, hospitalization, treatment or test that was not completed or results that you have not received (excluding HIV testing)?* This field is required.
Yes
No
100
Have you used alcoholic beverages? (If yes, how much, what kind (beer, wine, liquor) and how often?)* This field is required.
Yes
No
101
Have you ever had application for Life or Health Insurance declined, postponed, rated-up or limited?* This field is required.
Yes
No
102
In the next 12 months, do you plan to travel or reside outside of the United States or Canada?* This field is required.
Yes
No
103
DETAILS OF YES ANSWERS: Identify question number, the reason(s), medication taken and details of yes answers
104
How Many?
Age If Living
Present Health
Age at Death
Cause of Death
Father
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Mother
1
2
3
4
5
6
7
8
9
10
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Brothers
1
2
3
4
5
6
7
8
9
10
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Sisters
1
2
3
4
5
6
7
8
9
10
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Father
Mother
Brothers
Sisters
How Many?
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Age If Living
Row 0, Column 1
Present Health
Row 0, Column 2
Age at Death
Row 0, Column 3
Cause of Death
Row 0, Column 4
How Many?
1
2
3
4
5
6
7
8
9
10
Row 1, Column 0
Age If Living
Row 1, Column 1
Present Health
Row 1, Column 2
Age at Death
Row 1, Column 3
Cause of Death
Row 1, Column 4
How Many?
1
2
3
4
5
6
7
8
9
10
Row 2, Column 0
Age If Living
Row 2, Column 1
Present Health
Row 2, Column 2
Age at Death
Row 2, Column 3
Cause of Death
Row 2, Column 4
How Many?
1
2
3
4
5
6
7
8
9
10
Row 3, Column 0
Age If Living
Row 3, Column 1
Present Health
Row 3, Column 2
Age at Death
Row 3, Column 3
Cause of Death
Row 3, Column 4
1 of 4
105
Retirement Goals
Client
Spouse
Anticipated Retirement Age
Row 0, Column 0
Row 0, Column 1
Retirement Income Goal
Row 1, Column 0
Row 1, Column 1
Monthly Contribution Towards Retirement
Row 2, Column 0
Row 2, Column 1
Anticipated Retirement Age
Retirement Income Goal
Monthly Contribution Towards Retirement
Client
Row 0, Column 0
Spouse
Row 0, Column 1
Client
Row 1, Column 0
Spouse
Row 1, Column 1
Client
Row 2, Column 0
Spouse
Row 2, Column 1
1 of 3
106
Assessment/Dime
Client
Spouse
Student Loans
Row 0, Column 0
Row 0, Column 1
Car Loans
Row 1, Column 0
Row 1, Column 1
Credit Cards
Row 2, Column 0
Row 2, Column 1
Individual Total
Row 3, Column 0
Row 3, Column 1
TOTAL
Row 4, Column 0
Row 4, Column 1
Student Loans
Car Loans
Credit Cards
Individual Total
TOTAL
Client
Row 0, Column 0
Spouse
Row 0, Column 1
Client
Row 1, Column 0
Spouse
Row 1, Column 1
Client
Row 2, Column 0
Spouse
Row 2, Column 1
Client
Row 3, Column 0
Spouse
Row 3, Column 1
Client
Row 4, Column 0
Spouse
Row 4, Column 1
1 of 5
107
If you or your spouse could not work again, how much income would you need to sustain current lifestyle?* This field is required.
108
What is your house worth? What is your current balance?
If you rent, leave blank
109
Would you like to provide for your children's education? Approximate Cost:
If no or no children, leave blank
110
Monthly ExpensesThese amounts can be approximate BUT be sure to be as close to your actual monthly expenses as possible to ensure accurate Illustrations!
Dollar Amount
Mortgage/Rent
Row 0, Column 0
Utilities
Row 1, Column 0
Mobile Bill
Row 2, Column 0
Auto & Transportation
Row 3, Column 0
Food & Groceries
Row 4, Column 0
Child Care
Row 5, Column 0
Household Maintenance
Row 6, Column 0
Personal Expenses
Row 7, Column 0
Shopping
Row 8, Column 0
Car Insurance
Row 9, Column 0
Life Insurance
Row 10, Column 0
Health Insurance
Row 11, Column 0
Subscriptions
Row 12, Column 0
Entertainment
Row 13, Column 0
Investments
Row 14, Column 0
Debt & Loans
Row 15, Column 0
Charity & Gifts
Row 16, Column 0
Miscellaneous
Row 17, Column 0
TOTAL
Row 18, Column 0
Mortgage/Rent
Utilities
Mobile Bill
Auto & Transportation
Food & Groceries
Child Care
Household Maintenance
Personal Expenses
Shopping
Car Insurance
Life Insurance
Health Insurance
Subscriptions
Entertainment
Investments
Debt & Loans
Charity & Gifts
Miscellaneous
TOTAL
Dollar Amount
Row 0, Column 0
Dollar Amount
Row 1, Column 0
Dollar Amount
Row 2, Column 0
Dollar Amount
Row 3, Column 0
Dollar Amount
Row 4, Column 0
Dollar Amount
Row 5, Column 0
Dollar Amount
Row 6, Column 0
Dollar Amount
Row 7, Column 0
Dollar Amount
Row 8, Column 0
Dollar Amount
Row 9, Column 0
Dollar Amount
Row 10, Column 0
Dollar Amount
Row 11, Column 0
Dollar Amount
Row 12, Column 0
Dollar Amount
Row 13, Column 0
Dollar Amount
Row 14, Column 0
Dollar Amount
Row 15, Column 0
Dollar Amount
Row 16, Column 0
Dollar Amount
Row 17, Column 0
Dollar Amount
Row 18, Column 0
1 of 19
111
Monthly Income and Discretionary
Income
Client
Row 0, Column 0
Spouse
Row 1, Column 0
TOTAL
Row 2, Column 0
Discretionary
Row 3, Column 0
Client
Spouse
TOTAL
Discretionary
Income
Row 0, Column 0
Income
Row 1, Column 0
Income
Row 2, Column 0
Income
Row 3, Column 0
1 of 4
112
Taxable Assets
Dollar Amount
Savings
Row 0, Column 0
Checkings
Row 1, Column 0
CDs
Row 2, Column 0
Mutual Funds
Row 3, Column 0
Stocks
Row 4, Column 0
Bonds
Row 5, Column 0
Treasuries
Row 6, Column 0
Other
Row 7, Column 0
TOTAL
Row 8, Column 0
Savings
Checkings
CDs
Mutual Funds
Stocks
Bonds
Treasuries
Other
TOTAL
Dollar Amount
Row 0, Column 0
Dollar Amount
Row 1, Column 0
Dollar Amount
Row 2, Column 0
Dollar Amount
Row 3, Column 0
Dollar Amount
Row 4, Column 0
Dollar Amount
Row 5, Column 0
Dollar Amount
Row 6, Column 0
Dollar Amount
Row 7, Column 0
Dollar Amount
Row 8, Column 0
1 of 9
113
Taxable Deferred
Dollar Amount
IRA's
Row 0, Column 0
401k/403b/Pension
Row 1, Column 0
Variable Annuities
Row 2, Column 0
Fixed Annuities
Row 3, Column 0
Savings Bonds
Row 4, Column 0
Other
Row 5, Column 0
TOTAL
Row 6, Column 0
IRA's
401k/403b/Pension
Variable Annuities
Fixed Annuities
Savings Bonds
Other
TOTAL
Dollar Amount
Row 0, Column 0
Dollar Amount
Row 1, Column 0
Dollar Amount
Row 2, Column 0
Dollar Amount
Row 3, Column 0
Dollar Amount
Row 4, Column 0
Dollar Amount
Row 5, Column 0
Dollar Amount
Row 6, Column 0
1 of 7
114
Tax Advantaged
Dollar Amount
Roth IRA's
Row 0, Column 0
Cash Value Life Insurance
Row 1, Column 0
529 Plan or College<br />
Row 2, Column 0
Savings Programs
Row 3, Column 0
TOTAL
Row 4, Column 0
Roth IRA's
Cash Value Life Insurance
529 Plan or College<br />
Savings Programs
TOTAL
Dollar Amount
Row 0, Column 0
Dollar Amount
Row 1, Column 0
Dollar Amount
Row 2, Column 0
Dollar Amount
Row 3, Column 0
Dollar Amount
Row 4, Column 0
1 of 5
115
Please verify that you are human* This field is required.
Should be Empty:

Have you consulted a member of the medical profession for, been treated for, or been diagnosed as having:

Within the past 10 years: