Personal : Life Insurance

Client Information
First Name		MI		Last Name

Birth Date

Gender

MaleFemale

Height (ft. & in.)

Weight

Home Phone

Work Phone

Ext

Best Place to Call

HomeWork

Best Time to Call

MorningAfternoonEvening

Mailing Address (if different from household address)
Address
City			Zip/Postal Code

General Health Questions
In the past 36 months has the person to be covered used any form of tobacco?	YesNo
In the past 60 months has the person to be covered used any form of tobacco?	YesNo
Has the person to be covered ever been treated or sought treatment for diabetes, heart disease, cancer or cardiovascular disease?	YesNo
Has the person to be covered ever sought treatment or been advised to seek treatment for the use of drugs or alcohol?	YesNo
Has the person to be covered ever been treated for depression?	YesNo
In the past 5 years, has the person to be covered been convicted of driving under the influence of alcohol?	YesNo
In the past 3 years, has the person to be covered been convicted of 3 or more moving violations?	YesNo

Quote Information
Quote Type	BaseComparison
Tobacco Use	YesNo	Quote Age
Term Period	10 year15 year20 year30 year
Rate Class	PremierPreferredSelectStandardTable if you selected Table, please specify
Face Amount
Payment Mode	AnnualSemi AnnualQuarterlyMonthly
Flat Extra
Child Rider Coverage	$5,000$10,000$15,000$20,000
Premium Quoted

Additional Client Information
Is the owner the same as the insured?		YesNo
SSN#
Driver's License Number
Employer		Title
Specific Duties
Years Employed

Beneficiary Information
Class	Relationship*	Percent
Primary
Primary
Primary
Primary
Contingent
Contingent
Contingent
Contingent
* Business, Business Partner, Child, Estate, Ex-Spouse, Fiancee, Other, Parent, Sibling, Spouse, Testamentary Trust, Trust

Pre-Application Health Questions
Is the person to be covered taking or has the person to be covered ever been advised to take any medications?	YesNo
Has the person to be covered ever had, been treated for, or diagnosed with high blood pressure, diabetes, elevated cholesterol, fainting, seizure, alcoholism or depression?	YesNo

Other Insurance
Within the past 6 months, has the person to be covered applied for life insurance or is currently applying with another company?	YesNo
Will any existing life insurance or annuity be replaced or will values from another insurance policy or annuity be used to pay premiums for the policy applied for? If yes, please enter policy to replace below.	YesNo
Does the person to be covered have life insurance or annuities in force? If yes, please enter in force policy below.	YesNo

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