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Insurance Questionnaire
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1.
What is your first and last name?
(Required.)
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2.
Desired Face Amount?
(Required.)
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3.
Type of Insurance?
(Required.)
Term Life
Whole Life
Burial Insurance
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4.
Date of Birth?
(Required.)
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5.
What is your gender?
(Required.)
Female
Male
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6.
What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5’4”.
(Required.)
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7.
What is your current weight in pounds?
(Required.)
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8.
In the past 12 months have you used any form of tobacco?
(Required.)
Yes
No
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9.
Within the past 10 years, and to the best of your knowledge and belief, have you been treated for or told by a physician that you had any of the following? (select all that apply)
(Required.)
a. Hypertension?
b. Internal cancer, leukemia, or melanoma?
c. Heart disease, heart attack, or chest pain?
d. Stroke, TIA, or circulatory disorder?
e. Genitourinary or sexually transmitted disease?
f. Cirrhosis, chronic hepatitis, or liver disease?
g. Schizophrenia, bipolar, mental or nervous disorder?
h. Rectal bleeding or gastrointestinal disease?
i. Paralysis, blindness, or temporary vision loss?
j. Diabetes or pancreas disorder?
k. Lung or respiratory disorder?
l. Any other disease, injury, operation or deformity?
None of the above
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10.
Purpose of Coverage? Please select your main objective for obtaining life insurance coverage as well as any additional objectives that may apply.
(Required.)
SURVIVOR INCOME
TAX DEFERRED SAVINGS
RETIREMENT SUPPLEMENT
LONG TERM CARE PLANNING
ASSET DIVERSIFICATION
ASSET VALUE HEDGE
ESTATE LIQUIDITY
ESTATE EQUALIZATION
BUSINESS CONTINUITY | Buy-Sell Funding
BUSINESS CONTINUITY | Key Person Insurance
EXECUTIVE BENEFIT
ENHANCED CHARITABLE GIFTS
ASSET REPLACEMENT
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11.
What is your best contact number?
(Required.)
Current Progress,
0 of 11 answered
