Acme Inc.

Life Insurance Coverage Questionnaire

  1. Instructions

    1. Instructions

  2. Personal Information

    1. *Full Name

    2. *Date of Birth

    3. *Gender

    4. *Marital Status

    5. *Address

    6. Phone Number

    7. *Email Address

    8. *Are you a US citizen? If no, immigration status (Visa type, etc.)

    9. *Occupation

  3. Health Information

    1. *Have you ever been diagnosed with or treated for any of the following?

    2. Medications

    3. Details of any surgeries or hospital stays in the past 10 years

    4. *Do you use tobacco products?

    5. *Alcohol consumption habits

    6. *History of drug use (prescription or recreational)

    7. *Family history of serious illness (e.g., cancer, heart disease, diabetes)

  4. Lifestyle Information

    1. *How often do you exercise? (Frequency, type)

    2. *Any high-risk hobbies? (e.g., skydiving, scuba diving, mountain climbing)

    3. *Do you frequently travel internationally?

    4. *Any upcoming travel plans? (locations, duration)

  5. Coverage Information

    1. *Coverage in USD (e.g., $100,000, $500,000, $1 million)

    2. *Type of Life Insurance

    3. *Reason for Coverage

    4. Primary Beneficiary

    5. Contingent Beneficiary

    6. *Do you have any existing life insurance policies?

  6. Financial Information

    1. *Annual Income

    2. Your Total Net Worth

    3. Assets (real estate, investments, savings)

    4. Liabilities (loans, mortgages, credit card debt)

    5. *Number of dependents

    6. Ages of dependents

  7. Underwriting Information

    1. *Any criminal records? (any felony or misdemeanor)

    2. *Any bankruptcy history?

    3. *Any history of denied or postponed life insurance applications?

    4. *Any DUI/DWI in the past 5 years?

    5. *Number of speeding tickets or other traffic violations

    6. *Are you currently or have you ever been in the military?

    7. *Any deployments in high-risk zones?

  8. Existing Insurance

    1. *Please provide detail regarding existing insurance policies you have in place.

    2. *Are you working with an insurance agent?

  9. Additional Comments

    1. Any other relevant details or concerns regarding your application?

  10. Acknowledgment

    1. *I declare that the information provided is accurate and complete to the best of my knowledge.

Life Insurance Coverage Questionnaire


Life Insurance Coverage Questionnaire

Acme Inc.



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    Instructions

    This life insurance assessment focuses on your personal, medical, and financial details. Thank you for taking the time out to fill this questionnaire.



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    *Response requiredFull Name

    *Response requiredDate of Birth

    *Response requiredGender

    • Female

    • Male

    • Transgender

    • Non-binary

    *Response requiredMarital Status

    • Single

    • Married

    • Divorced

    • Widowed

    *Response requiredAddress

    Street Address, City, State, Zip Code

    Phone Number

    +31

    *Response requiredAre you a US citizen? If no, immigration status (Visa type, etc.)

    *Response requiredOccupation

    *Response requiredHave you ever been diagnosed with or treated for any of the following?

    • High Blood Pressure

    • Heart Disease

    • Diabetes

    • Cancer

    • Chronic Lung Disease (e.g., Asthma, COPD)

    • Kidney or Liver Disease

    • Mental Health Issues (e.g., Anxiety, Depression)

    Medications

      • Current prescription medication

      • Dosages and duration of usage

    • Add an item

    Details of any surgeries or hospital stays in the past 10 years

    *Response requiredDo you use tobacco products?

    Include type, quantity, duration.

    *Response requiredAlcohol consumption habits

    Include frequency and quantity of use.

    *Response requiredHistory of drug use (prescription or recreational)

    *Response requiredFamily history of serious illness (e.g., cancer, heart disease, diabetes)

    *Response requiredHow often do you exercise? (Frequency, type)

    *Response requiredAny high-risk hobbies? (e.g., skydiving, scuba diving, mountain climbing)

    *Response requiredDo you frequently travel internationally?

    *Response requiredAny upcoming travel plans? (locations, duration)

    *Response requiredCoverage in USD (e.g., $100,000, $500,000, $1 million)

    *Response requiredType of Life Insurance

    • Term Life Insurance

    • Whole Life Insurance

    • Universal Life Insurance

    *Response requiredReason for Coverage

    • Income replacement

    • Estate planning

    • College education funding

    • Mortgage protection

    • Business purposes

    Primary Beneficiary

    Contingent Beneficiary

    *Response requiredDo you have any existing life insurance policies?

    Policy details (company, amount, duration)

    *Response requiredAnnual Income

    Your Total Net Worth

    Assets (real estate, investments, savings)

    Liabilities (loans, mortgages, credit card debt)

    *Response requiredNumber of dependents

    Ages of dependents

    *Response requiredAny criminal records? (any felony or misdemeanor)

    *Response requiredAny bankruptcy history?

    *Response requiredAny history of denied or postponed life insurance applications?

    *Response requiredAny DUI/DWI in the past 5 years?

    *Response requiredNumber of speeding tickets or other traffic violations

    *Response requiredAre you currently or have you ever been in the military?

    *Response requiredAny deployments in high-risk zones?

    *Response requiredPlease provide detail regarding existing insurance policies you have in place.

    *Response requiredAre you working with an insurance agent?

    • Yes

    • No

    Any other relevant details or concerns regarding your application?

    *Response requiredI declare that the information provided is accurate and complete to the best of my knowledge.

    • I acknowledge