Life Insurance Questionnaire
Name
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Date of Birth
*
Female/Male
*
Please Select
Female
Male
How tall are you? (feet', inches")
*
Your tall height - round up please :)
What is your weight today?
*
Be as exact as you can or provide a realistic range of lightest and heaviest in the last 30 days
Any tobacco or nicotine in the last 5 years?
*
Please Select
No
Yes
Includes cigarettes, dip, chew, vape, etc
Please describe tobacco or nicotine use. The more detail the better. What do you use? How much and how often did/do you use it? When was the last time you used nicotine or tobacco and what exactly was it?
What are your children's ages?
*
If none, type none.
If you passed away today, about how much other life insurance would be available?
*
Best guess is fine. Add up your other life insurance policies, work life policies, etc.
If you passed away today, besides other life insurance, about how much money could be accessed quickly?
*
Best guess is fine. Add up your liquid assets like savings accounts, certificates of deposit, or other assets that could be easily liquidated if needed.
In the past 10 years, have you been diagnosed or treated for: (select all that apply)
*
High Blood Pressure
High Cholesterol
Thyroid Disorder
Asthma
Sleep Apnea
Crohn's or UC
Depression/Anxiety
ADD/ADHD
None of the above
How much coverage would you like rates for? (select all that apply)
*
$100,000
$150,000
$250,000
$350,000
$500,000
$750,000
$1,000,000
$1,250,000
$1,500,000
Help me figure this out!
Approximate Annual Income:
*
Your individual income. Best guess is fine.
Approximate Household Income:
*
Household total annual, best guess is fine.
Do you have any other health conditions or concerns?
Please list below any other questions or comments or items that you think are important or you are concerned with so I can best help you accomplish your goal.
Please verify that you are human
*
Submit
Should be Empty: