Proud Members

Site Search:

Life Insurance Client Questionnaire

All fields are required.

Proposed Insured
First Name	Middle Name	Last Name
Date of Birth	Occupation	Male Female
Address
City	State	ZIP
Telephone (Day)	(Evening)	Best Time to Call
Have you ever used tobacco? Yes No	Date Last Used	Type
Email Address		Place of Birth
Height	Weight	Social Security #
U.S. Citizenship/Green Card or U.S. Visa Type and #
Driver's License #		State
Do You Have Existing Life Insurance? Yes No		Replacement? Yes No
Existing Policy Face Amount	If Replacement, Name of Company
Policy Number	Plan Type
Year Issued	Beneficiary
Owner's Name (if different from the proposed insured)
Owner's Address
Social Security # or Tax ID #		Date of Birth
Owner's Relationship to the Insured
Primary Beneficiary(ies) and percentages
Social Security or Tax ID #	Date of Birth	Relationship
Contingent Beneficiary(ies) and percentages
Social Security #	Date of Birth	Relationship

Proposed Coverage Details
Death Benefit	Term Period
Payment Mode: A S/A Q M
Purpose of Insurance		Personal Business
Has the proposed insured ever been rated, postponed or declined for life insurance? Yes No

Is there an application for life insurance coverage pending at any other company? Yes No


Family History
Is there a family history of cancer? Yes No
	Age of onset?
Is there a family history of heart disease? Yes No
	Age of onset?	Age if death occurred
Prescription medications currently used
Has the proposed insured ever been convicted of a DUI
Does the proposed insured currently consume alcohol?
If so, daily/weekly/monthly alcohol usage
Any history of illegal drug use?
Has the proposed insured had more than two moving violations in the past three years? Yes No

Has a parent or sibling had a history of heart disease or cancer prior to age 65? Yes No
	If so, what age?	Age at death?
Total Annual Income	Total Assets	Total Liability

Insurance Exam Preferences
Date	Time	AM PM
Best phone number to call

*HOLD HARMLESS*
The insurance broker and any other persons or agencies are held harmless from any loss or damages arising from health insurance, life insurance, indemnity or supplemental benefits on the surrogate, Intended parent or egg donor being denied or accepted for coverage. New Life Agency, Insurance Agency does not make any representations regarding the insurance policies referenced herein or otherwise and is not in any way responsible for the coverage of such insurance or loss or damages from the denial of any claims under such policies. Health insurance, life insurance, indemnity or supplemental benefits and exclusions can and may change without notice.