Personal Information

Legal Name *

(full first, middle, last)

Street Address

City

State

Country

Postal Code

How long at current address?

Date of Birth *

MM-DD-YYYY

Where Were You Born? *

(state, or country)

Phone *

best to reach you? (and/or Spouse)

Email *

Driver’s License Number *

Social Security Number *

Financial Information

Annual Income

Net Worth

(List the total estimated value of assets, including real estate, retirement accounts, savings, other assets, and total debts, either held individually or jointly if married or have a life partner. )

Employer and how long there

Occupation

(duties)

Health Information

Height *

Weight *

(details if changed 10 or more pounds in the last 12 months)

List all prescription medications, how long taking, and related condition(s)

Diabetes diagnosed or blood sugar (A1C) ever high over 6.0

(dates, readings, list any meds)

Family History - Any heart disease or cancer diagnosed with parents or siblings before age 60?

If so, which family member, approximate age they were diagnosed, if they are still living, and their current age. If deceased, what age did they pass?

Risk Information

Hazardous Activities - Fly any aircraft as a pilot or crew member, scuba dive, sky dive, rock or mountain climbing, vehicle racing, or plan do so in the next year?

If you are in the military, what is your rank, where are you stationed, what are your duties, and whether a retirement or overseas tour is planned in the next year?

DUIs in the past ten years?

(details, dates)

Treated for Alcohol or recreational drugs - ever use?

(details, rehab, dates):

Nicotine or cannabis use currently or in the past three years?

(If so, which form of nicotine: cigarettes, vape, cigars, chewing, packets, gum, lozenges, or patches? If any cannabis use, how frequently (daily, weekly, or how many times in the past year) and form- flower, edibles, vaping, or other form?)

*Life insurance companies vary in how they rate policies for the use of these substances. The more accurate your description, the more accurate your rate will be. We can also advise which companies are more lenient based on their underwriting guidelines.

Mental/Nervous disorders or issues - ever have?

(anxiety, depression, seizures, tremors, dementia, fainting, etc.)

Cancer or Heart condition ever?

(details, dates)

Surgeries in the last 5 years?

(total #, details, dates)

Other Conditions like autoimmune disorders- RA, PA, Crohn's- ever have?

(details & dates of illnesses or anything affecting insurability?)

Doctor(s)

(names, location & date last visit)

US Citizen *

Yes

If not a US Citizen, what type of visa do you have: Green Card, H1B or list specific visa, and how long have you lived in the US?

Beneficiary(s)

(Name, relationship and date of birth)

% to be received

(Name, relationship, % of benefit to receive, and date of birth)

Do you have any existing life insurance?

(If so, please list the company name if you know it, face amount(s), if individual or group, and if you plan to replace any existing life insurance coverage.)