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Life Insurance

Pre-Appointment Intake Form

Life Insurance is not a one-size-fits-all solution.

That's why we've developed this Pre-Appointment Intake Form to help us identify your unique needs and requirements. By completing this form, you'll be helping us do our due diligence so that we can provide you with the best possible advice and recommendations.

State

Date of Birth

Physical Gender

M

F

In the last two years have you used any Tobacco products?

Yes

No

Do you have any other Life Insurance policies in force today that you intend to keep or replace?

What type of Life Insurance would you like quote(s) for?

Term Life Insurance

Final Expense Life Insurance (50-85 years old)

Guaranteed Universal Life Insurance (GUL)

Index Universal Life Insurance (IUL)

Whole Life Insurance

Rx List

Have you ever tested positive for HIV or AIDS?

Yes

No

Have you ever had diabetes, especially early-onset or complicated diabetes?

Yes

No

In the past year, have you needed significant medical assistance?

Yes

No

In the past year, have you undergone any non-routine procedures or been treated for chronic conditions?

Yes

No

In the past decade, have you had any substance abuse treatment or felony convictions?

Yes

No

In the past five years, have you had any DUIs, reckless driving convictions, or hospitalization for high blood pressure, mental disorders, or multiple traffic violations?

Yes

No

List all providers you've seen in the last 3 years