LIFE INSURANCE QUESTIONNAIRE
This questionnaire ensures thorough and efficient data collection for life insurance quoting and setup.
Full Name
*
First Name
Last Name
Email
*
example@example.com
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Policy Type:
*
Term Life Insurance (Coverage for a fixed period)
Whole Life Insurance (Lifetime coverage with cash value)
What is most important to you?
*
Estate Planning
Education Protect
Retirement Enhancer
Life Cover
Income Protector
Debt Protect
Will and Testaments
Critical Illness Protect
Disability Protect
Funeral Protect
Commercial Lines short term insurance
Personal line short term insurance
Would you like a?
*
New Quotation
Comparison
Portfolio Review
Other
Do you smoke or use Alcohol?
*
YES
NO
Height (CM) & Weight (KG)
(Used for health risk assessment during underwriting.)
What are your top priorities?
*
Providing for your family’s daily needs
Paying off debts (e.g., mortgage, car loans)
Securing children’s education
Leaving a financial legacy
Occupation and Employer Name:
*
How would you like to meet?
*
In Person (Depending on location)
Online (via Zoom)
Initials
*
SUBMIT
SUBMIT
Should be Empty: