Client Information Sheet - Life Insurance

Enter Client Details

First Name *

Last Name *

Date of birth

MM-DD-YYYY

Place of Birth

Height

Weight

Social Security Number

Gender

ID/Driver License Number

ID/Driver License Number Expiration Date

Address

Street Address

City

State

Country

Postal code

Years at Current Address

Phone *

Email *

Marital Status

U.S Citizen?

State of Birth

How long have you been in the USA?

Finances

Taxable Accounts

Savings
Checking
CDs
Mutual Funds
Stocks
Bonds
Treasuries

Taxable Account Notes

Total Taxable Amount

Tax Deferred Accounts

IRAs
401(k), 403(b) and other pension assets
Fixed Annuities
Variable Annuities
Saving Bonds
Others

Tax Deferred Account Notes

Total Tax Deferred Amount

Tax Advantage Accounts

Roth IRA
Cash Value Life Ins.
529 Plan or College
Savings Programs

Tax Advantage Account Notes

Total Tax Advantage Amount

Other Life Insurance Policies

Other Life Insurance Policies Notes

Employment Information

Employer Name

Position

Type of Business/Industry

How Long at Current Job?

Employer's Full Address

Annual Income

Net Worth

Doctor Information

Primary Doctor Name or Clinic Name

Primary Doctor's Phone Number

Doctor's Full Address

Last Doctor Visit

Reasons/Results of Last Visit

Beneficiaries

Beneficiary Full Name #1

Beneficiary Relationship #1

Beneficiary Date of Birth #1

MM-DD-YYYY

Beneficiary Percentage #1

in %

Primary or Contingent - Beneficiary #1

Beneficiary Full Name #2

Beneficiary Relationship #2

Beneficiary Date of Birth #2

MM-DD-YYYY

Beneficiary Percentage #2

in %

Primary or Contingent - Beneficiary #2

Beneficiary Full Name #3

Beneficiary Relationship #3

Beneficiary Date of Birth #3

MM-DD-YYYY

Beneficiary Percentage #3

in %

Primary or Contingent - Beneficiary #3

Additional Beneficiary Section

Child Information

Will you be adding coverage for a juvenile?

Child Full Name #1

Child Date Of Birth #1

MM-DD-YYYY

Child Birthplace #1

Child Height #1

Child Weight #1

Child Social Security Number #1

Child Full Name #2

Child Date Of Birth #2

MM-DD-YYYY

Child Birthplace #2

Child Height #2

Child Weight #2

Child Social Security Number #2

Child Full Name #3

Child Date Of Birth #3

MM-DD-YYYY

Child Birthplace #3

Child Height #3

Child Weight #3

Child Social Security Number #3

Additional Children

Policy Owner

Will the payor be different from the owner?

Owner's First Name

Owner's Last Name

Owner's Phone Number

Owner's Date of Birth

MM-DD-YYYY

Owner's Social Security Number

Owner's Driver License Number

MM-DD-YYYY

Owner's Street Address

Owner's City

Owner's State

Owner's Zip Code

Banking Information

Bank Name

Name on Account

Bank Account Number

Bank Routing Number

Preferred Draft Date (1st – 28th)

Questionnaire

In the last five years, have you used any form of nicotine or ever tried or experimented with marijuana? If yes, please explain usage.

What are your parents' ages, and are they still living? If they have passed away, please explain the cause of death. How many siblings do you have, and are they brothers or sisters? Are they alive or have they passed away? If any siblings have passed away, please explain the cause of death.

Have you ever been diagnosed with or treated for any major medical conditions? If yes, please provide details.

Do you take medication regularly?

If yes, list the medication, done, and frequency.

Do you consume alcohol? If yes, would you consider yourself a light, moderate, or heavy drinker?

Agent Information

Writing Agent Full Name

Split Agent Full Name

Policy Notes:

Upload clear copy of an ID, Passport, Visa or ITIN Letter

Upload up to 4 files

PDF, DOCX, DOC, JPEG, JPG or PNG ( max 4 Files )

Attach Client Illustrations for Processing

Up to 3 Illustrations

PDF, JPEG, JPG, PNG, DOCX or DOC