We want to help you protect what you value most! Client Qualification Form for Life insurance Please complete to allow us to prepare life insurance options that suit your individual and family needs. Name* First Last Phone*Email Date of Birth MM slash DD slash YYYY Occupation Tobacco/Nicotine Use Yes No Please note in the remarks at the bottom of the form the type of tobacco products used and frequency. (cigarettes, chewing tobacco, vape, cigars, etc)Health Problems/ConditionsHigh Blood Pressure/ Heart Conditions/ Sleep Apnea/ Stroke/ Cancer/ Diabetes/ Other Diseases or DisordersMedicationsInclude name of medication and dosage/frequency Spouse/Other First Last Date of Birth MM slash DD slash YYYY Occupation Tobacco Use Yes No Please note in the remarks at the bottom of the form the type of tobacco products used and frequency. (cigarettes, chewing tobacco, vape, cigars, etc)Health Problems/ConditionsHigh Blood Pressure/ Heart Conditions/ Sleep Apnea/ Stroke/ Cancer/ Diabetes/ Other Diseases or DisordersMedicationsInclude name of medication and dosage/frequency What would you like your life insurance to do for you?* Select All Replace Income (pay for ongoing family expenses) Pay off mortgage Pay off other debts (cars, college loans, etc) Burial Expenses Business Perpetuation Leave an inheritance Grow cash value/savings Pay for children's college Who would you list as the beneficiary? Name(s) and relation of loved one, family member, estate, charitable organization, etc.Current Mortgage Balance Do either of you have any life insurance? Yes, through work Yes, coverage I pay for currently No If yes, how much coverage do you have? Remarks/Questions/ConcernsEmailThis field is for validation purposes and should be left unchanged.
