INSURANCE CLIENT INTAKE FORM

Personal Information

Name * Required

Date of Birth * Required

Social Security Number

Driver's License Number

Gender * Required

Marital Status * Required

Email

Primary Phone Number * Required

Secondary Phone Number

Address * Required

Mailing Address (if different from above)

Employment & Financial Information

Employment Status * Required

Company Name

Job Title

Industry/Sector

Years at Current Employer

Annual Household Income

$

Net Worth (approximate)

$

Coverage Requested

Insurance type(s) requested * Required

Life Insurance

Medicare

Dental Insurance

Accident Insurance

Health Insurance

Home Insurance

Desired Coverage Amount * Required

$

Desired Start Date

Current Insurance Provider (if any)

Current Policy Number

Current Insurance Expiration Date

Beneficiary Information

Primary Beneficiary Full Name

Primary Beneficiary Relationship

Primary Beneficiary Date of Birth

Primary Beneficiary Share %

Primary Beneficiary Phone/Email

Primary Beneficiary Address

Contingent Beneficiary Full Name

Contingent Beneficiary Relationship

Contingent Beneficiary Date of Birth

Contingent Beneficiary Share %

Contingent Beneficiary Phone/Email

Contingent Beneficiary Address

Health & Medical Information

Height

Weight (lbs)

Do any of the following apply?

Have you been hospitalized in the past 5 years?

Do you have any chronic or ongoing medical conditions?

Have you been diagnosed with cancer, heart disease, or diabetes?

Do you regularly take prescription medications?

Have you had surgery in the past 3 years?

Have you been declined coverage by another insurer?

Do you engage in hazardous sports or occupations?

If you checked any of the above, please provide more details.

Tobacco/Nicotine User?

Primary Care Physician Name

Physician Phone

Life Insurance Details

Life Insurance Policy Type

Lifestyle & Risk Assessment

Do any of the following factors apply?

Do you participate in aviation (as a pilot or passenger)?

Do you scuba dive, rock climb, or skydive?

Do you travel internationally more than 3 times per year?

Do you own or operate firearms as part of your occupation?

Have you filed an insurance claim in the past 3 years?

If you checked any of the above, please provide more details.

Referrer Information

How did you hear about us?

Referrer Name (if applicable)

Disclosures & Authorizations

By signing below, I/We confirm that all information provided in this form is true, accurate, and complete to the best of my/our knowledge. I/We authorize the insurer and its representatives to verify any information provided herein, including medical records where applicable, for the purpose of underwriting and policy issuance. I/We understand that any misrepresentation or omission of material facts may void coverage. I/We acknowledge receipt of the privacy notice and consent to the collection, use, and disclosure of personal information in accordance with applicable privacy legislation. I/We agree that this application does not bind the insurer to issue a policy.

Applicant Signature * Required

Printed Name * Required

Date * Required

Co-Applicant Signature (if applicable)

Co-Applicant Printed Name

Date