Inter-Ocean Insurance Agency
Life Insurance Application Form
Customer Information
Title
*
Mr.
Mrs.
Miss
Other
Full Name
*
First Name
Last Name
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
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October
November
December
Month
Please select a day
1
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31
Day
Please select a year
2026
2025
2024
2023
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2021
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1927
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1925
1924
1923
1922
1921
1920
Year
Marital Status
*
Single
Married
Divorced
Widow(er)
E-mail
*
example@example.com
Phone Number
*
Residential Address
*
Residential Address
Residential Address Line 2
City
State / Province
Postal / Zip Code
Use my Residential Address as my mailing address
Mailing Address
*
Mailing Address
Mailing Address Line 2
City
State / Province
Postal / Zip Code
Coverage Information
Do you know the amount of coverage that you would like?
*
Yes
No
Coverage Amount
Do you know the type of coverage that you would like?
*
Yes
No
Type of Policy
Term Life
Whole Life
Universal Life
Other
Monthly Budget for UL Policy
Length of Term
30 Years
25 Years
20 Years
15 Years
10 Years
Dependent Information
Any dependents that rely on your financial support?
*
Yes
No
Dependents
Rows
Full Name
Date of Birth
Spouse (If applicable)
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Financial Information
What's your main purpose in applying for this coverage?
*
Cover mortage
Cover other debt
Cover funeral/burial costs
Act as a savings account
Provide financial support for dependent(s)
Other
Financial Picture (Optional but helpful)
Rows
Amount
Annual Income
Monthly Budget for Life Insurance
Mortgage Outstanding
Car Loans Outstanding
Other Debt Outstanding
Savings/Checking Balance
Investment Account Balance
Retirement Account Balance
Market Value of Home
Value of Other Assets
Health Information
Height
*
Weight
*
Have you ever used nicotine products?
*
Yes
No
Do you currently use nicotine products?
*
Yes
No
Products used?
*
Cigarettes
Chewing Tobacco
Cigars
Other
Any health issues? (ex: high blood pressure, heart disease, diabetes, cancer, high cholesterol, etc.
*
Yes
No
Please describe
*
Rows
Date Diagnosed
Condition
Current Treatment
Health Issue 1
Health Issue 2
Health Issue 3
Health Issue 4
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Submit
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