Life Insurance Questionnaire

Full Name

Date of birth

Marital Status

Single
Married
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Sex

Male

Female

Address

County

Phone *

Email *

Social Security Number

Driver's License No. & State

State of Birth

Country of Birth

Height

Weight

Job Name

Beneficiary’s Info:

1. Full Name

Gender

Male
Female
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Phone Number

Date of Birth

Relationship to the Owner

Full Address

Do they need insurance?

Yes
No
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Do you mind if we give them a call as well?

Yes
No
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2. Full Name

Gender

Male
Female
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Phone Number

Date of Birth

Relationship to the Owner

Address

Do they need insurance?

Yes
No
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Do you mind if we give them a call as well?

Yes
No
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3. Full Name

Gender

Male
Female
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Phone Number

Date of Birth

Relationship to the Owner

Address

Do they need insurance?

Yes
No
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Do you mind if we give them a call as well?

Yes
No
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Health Questions

Tobacco Question

1. In the past (12) months, has the applicant used any form of tobacco?

Yes
No
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Uninsurable Conditions

1. Has the applicant tested positive for HIV or been diagnosed by a physician as having AIDS or a life expectancy of twelve (12) months or less?

Yes
No
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2. Is the applicant currently bedridden, hospitalized, in a care facility, or receiving hospice care?

Yes
No
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Significant Health Conditions

If the answer to any health question is “Yes”, your death benefit will be modified.

In the past two (2) years, has the applicant been diagnosed with, been treated by a physician, or taken medication for any of the following conditions:

1. Disease of the heart, including heart attack, heart surgery, or congestive heart failure?

Yes
No
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2. Disease of the circulatory system, including stroke, aneurysm, or been advised to have surgery to improve circulation?

Yes
No
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3. Cancer, other than basal cell skin cancer?

Yes
NO
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4. Disease of the lungs, including COPD or emphysema, other than asthma?

Yes
No
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5. Disease of the liver or kidney, or had an organ transplant?

Yes
No
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6. Alzheimer's disease, dementia, organic brain syndrome, or ALS (Lou Gehrig's disease)?

Yes
No
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7. Alcohol or drug abuse?

Yes
No
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8. Complications of diabetes, including amputation, diabetic coma, blindness, or kidney disorder?

Yes
No
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9. Has the applicant had or been advised to have a diagnostic test relating to any of the questions listed above, except for those relating to the Human Immunodeficiency Virus (AIDS virus), for which results have not yet been received?

Yes
No
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__________________________________________________

Does the applicant have existing life insurance or annuity contracts?

Yes
No
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Will this policy replace or change other insurance or annuities?

Yes
No
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Additional Notes:

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.