New Life Insurance Client Intake Form

Confidentiality Statement

1. Insurance Planning

Current Insurance Policies:

a. Whole Life Face Value: $

Age of Policy

Whole Life Face Value: $

Age of Policy

Whole Life Face Value: $

Age of Policy

b. Term Life Face Value: $

Expiration Date

Term Life Face Value: $

Expiration Date

Term Life Face Value: $

Expiration Date

c. Health Insurance Company:

Expiration Date

d. Other Life Ins. Face Value: $

Expiration Date

2. Life Insurance Strategy

a.Why are you purchasing life insurance?

To provide $ to

i. To provide $ to 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. Annuities

a. Why are you purchasing an annuity?

i. Retirement Planning? $

ii. When will you need your annuity? (Date)

4. Appllicant's Data:

Name:

Date of Birth:

Height:

Weight: (lbs)

Phone #:

Email: *

Current Address:

City:

State:

Zip Code

Current Health Condition: (On a Scale of 1-5)

Tobacco Use:

Former (How many years)

Drug Use:

Former (How many years)

5 Remarks, Other Insurance Products Inquiry, Questions