New Life Insurance Client Intake Form *Confidentiality Statement* New Life Insurance Client Intake Form 1. Insurance Planning Current Insurance Policies: a. Whole LifeFace Value: $Age of PolicyFace Value: $Age of PolicyFace Value: $Age of Policyb. Term LifeFace Value: $Expiration Date: MM slash DD slash YYYY Face Value: $Expiration Date: MM slash DD slash YYYY Face Value: $Expiration Date: MM slash DD slash YYYY c. Health InsuranceCompany:Expiration Date: MM slash DD slash YYYY d. Other Life Ins. Face Value: $Expiration Date: MM slash DD slash YYYY 2. Life Insurance Strategya. Why are you purchasing life insurance?i. To provide $Upon my death.ii. I need enough insurance to cover:a) Home Mortgage $b) Car Loan(s) $c) Combined Personal Debt $d) Income Replacement for (__ ) years $e) Children’s College $f) Children/Grandchildren Inheritance $g) Other Coverage $iii. Of the insurance total coverage, how much should be permanent insurance? $ 3. Applicant’s Data:NameDate of Birth: MM slash DD slash YYYY Height:(Ft&in)Weight(lbs) PhoneEmail Current Address City State / Province / Region ZIP / Postal Code Current Health Condition: (On a Scale of 1-5) 1 2 3 4 5 Tobacco Use: Yes Never Former (How many years)Drug Use Yes Never Former (How many years) 4. Fixed Annuities a. Why are you purchasing an annuity? i. Retirement Planning? $ii. When will you need your annuity? (Date) MM slash DD slash YYYY iii. What would you like for your annuity to do? 5. Remarks, Other Insurance Products Inquiry, Questions: CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
