Insurance Questionnaire

Question Title

* 1. What is your first and last name?

Question Title

* 2. Desired Face Amount?

Question Title

* 3. Type of Insurance?

Term Life

Whole Life

Burial Insurance

Question Title

* 4. Date of Birth?

Question Title

* 5. What is your gender?

Female

Male

Question Title

* 6. What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5’4”.

Question Title

* 7. What is your current weight in pounds?

Question Title

* 8. In the past 12 months have you used any form of tobacco?

Yes

Question Title

* 9. Within the past 10 years, and to the best of your knowledge and belief, have you been treated for or told by a physician that you had any of the following? (select all that apply)

a. Hypertension?

b. Internal cancer, leukemia, or melanoma?

c. Heart disease, heart attack, or chest pain?

d. Stroke, TIA, or circulatory disorder?

e. Genitourinary or sexually transmitted disease?

f. Cirrhosis, chronic hepatitis, or liver disease?

g. Schizophrenia, bipolar, mental or nervous disorder?

h. Rectal bleeding or gastrointestinal disease?

i. Paralysis, blindness, or temporary vision loss?

j. Diabetes or pancreas disorder?

k. Lung or respiratory disorder?

l. Any other disease, injury, operation or deformity?

None of the above

Question Title

* 10. Purpose of Coverage? Please select your main objective for obtaining life insurance coverage as well as any additional objectives that may apply.

SURVIVOR INCOME

TAX DEFERRED SAVINGS

RETIREMENT SUPPLEMENT

LONG TERM CARE PLANNING

ASSET DIVERSIFICATION

ASSET VALUE HEDGE

ESTATE LIQUIDITY

ESTATE EQUALIZATION

BUSINESS CONTINUITY | Buy-Sell Funding

BUSINESS CONTINUITY | Key Person Insurance

EXECUTIVE BENEFIT

ENHANCED CHARITABLE GIFTS

ASSET REPLACEMENT

Insurance Questionnaire

Question Title

* 1. What is your first and last name?

Question Title

* 2. Desired Face Amount?

Question Title

* 3. Type of Insurance?

Question Title

* 4. Date of Birth?

Question Title

* 5. What is your gender?

Question Title

* 6. What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5’4”.

Question Title

* 7. What is your current weight in pounds?

Question Title

* 8. In the past 12 months have you used any form of tobacco?

Question Title

* 9. Within the past 10 years, and to the best of your knowledge and belief, have you been treated for or told by a physician that you had any of the following? (select all that apply)

Question Title

* 10. Purpose of Coverage? Please select your main objective for obtaining life insurance coverage as well as any additional objectives that may apply.

Question Title

* 11. What is your best contact number?