Personal Information

Legal Name *

(full first, middle, last)

Street Address

City

State

Country

Postal Code

Year Moved In

Date of Birth *

MM-DD-YYYY

Where Were You Born? *

(state, or country)

Phone *

best to reach you? (and/or Spouse)

Driver’s License Number *

Social Security Number *

Financial Information

Annual Income & Net Worth

(estimated assets minus liabilities)

Employer

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 - prior to age 60 – natural dad, mom, or sibling… with heart, cancer or diabetes?

(relationship, illness, date diagnosed, if cause of death date died)

Risk Information

Hazardous Activities - ever engage in any risky activities (flying, racing, diving, climbing, etc.)

(dates, details)

DUIs in the past ten years?

(details, dates)

Treated for Alcohol or recreational drugs - ever use?

(details, rehab, dates):

Nicotine/Cannabis ever used?

(details & dates for tobacco, smoking, chewing, packets, vaping, gum, lozenges, Chantix or edibles):

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

Beneficiary(s)

(Name, relationship and date of birth)

If not, provide status, such as green card, exact type visa, etc..

Supplemental Group Life

(death benefit & premium paid)

Individual Life - Do you have coverage now? Plan to replace?

(give type, effective date, death benefit, premium, years initially guaranteed, etc., for each policy)