CLIENT WORKSHEET

Fill out the form to get the best rates for your client.

Use different emails and phone numbers if submitting both forms.

PROPOSED INSURED #1

PROPOSED INSURED #2

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PAGE #1

CLIENT INFORMATION #2

Full Name

Email *

Phone *

Date of Birth *

Gender

Height / Weight (lb)

HEALTH QUESTIONS

Have you ever been diagnosed with any of the following:

In the past twelve (12) months, has the applicant used any form of tobacco?
Has the applicant tested positive for HIV or been diagnosed by a physician as having AIDs or a life expectancy of twelve (12) months or less? Is the applicant currently bedridden, hospitalized, in a care facility, or receiving hospice care? Receive assistance with daily living activities such as taking medications, bathing, toileting, dressing, or eating?
Disease of the heart, including heart attack, heart surgery or congestive heart failure? Disease of the circulatory system, including stroke, aneurysm, seizure, lupus, sickle cell anemia or been advised to have surgery to improve circulation? Any Cancer, other than basal cell skin cancer?
Disease of the lungs, including COPD, chronic asthma or the use of oxygen, nebulizers or nitroglycerin? Any Disease of the liver or kidney, including insulin dependent diabetes, Hepatitis B or C, or had an organ transplant? Complications of diabetes, such as amputation, diabetic coma, blindness, neuropathy or kidney disorder?
In the past twelve (12) months, has the applicant been confined to a hospital more than twice or had any surgeries? Recommended to have counseling for alcohol, drug abuse, convicted of a DUI, felony or on parole?
Depression, bipolar disorder, schizophrenia, or memory loss including Alzheimer’s, dementia or ALS (Lou Gehrig’s disease)?

Insert conditions in "Health Conditions & Meds"

Are you retired or still working? *

Please list the clients health conditions & medications below: *

▪️ NOTE: Insert the clients diagnose dates and treatment dates

PAGE #2

Rate Class

Insurance Company

Policy Type

Chosen Coverage Amount (Wait to fill until client chooses coverage)

BENEFICIARY SECTION

Primary Beneficiary(s) / Relationship

Contingent Beneficiary(s) / Relationship

PRE-QUALIFYING WORKSHEET

Home Address

Q: "What is the best address to mail the policy to?"

City

State

Postal code

PROPOSED INSURED SECTION

Policy Owner

Drivers License / State ID

Q: They need to verify your identity, what is your drivers license #?

Primary Doctor / City & State

Social Security (SSN)

Q: They are going to run your MIB report to see if your eligible, whats your social?

PLAN & PAYMENT INFO

Effective Draft Date

Q: Upon approval when do you want your policy to start?

Name of Institution (Bank)

Routing Number

Account Number

Monthly Payment $

Policy Number

NOTES:

Begin the application process with your selected life insurance carrier. Keep the client on the phone as you submit!