Life Insurance Questionnaire (US)

Instructions

Thank you for taking the time out to fill this questionnaire.

What do you need to know?

Provide all required information here using this form.
Click ✓ Ok to submit and check off each request.
Drafts are saved automatically and your progress restored (so you don't have to complete the checklist in one go

Need help?

Click the message icon in the top left corner to leave a message or comment for the question or section you're stuck in or need help with.

Getting started

Click the ✓ Ok button below to get started.

*Please provide your full name.

*Please provide your date of birth.

*Please indicate your birth state/country.

*Please indicate your gender.

Female
Male
Transgender
Non-binary

*Please provide your social security number.

*Please provide your current address.

This includes your house number, street address, city, province and zip/postal code.

*How many years have you been at this address?

*Please provide your home phone number.

Please provide an alternative personal contact number.

This should be your primary moblie number.

Please provide your work phone number.

*Please provide your primary email address.

*Are you a US citizen?

Yes
No

*What is your occupation?

*Please provide your employer's name.

*Please provide your employer's contact number.

*Please provide your employer's current address.

*Please indicate your annual income.

*Please indicate your household income.

*Please indicate your total liabilities.

This refers to any debt.

*Please indicate your total net-worth.

*Please indicate your driver's licence details.

This includes your driver’s License Number, State, and Expiration.

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

Please separate these onto different lines and, for each, indicate the company, the amount of

insurance, the year of issue, the type (Term, Whole Life, UL, VUL), policy number and current premium.

*Has the proposed insured applied for any additional life insurance with another carrier?

Yes
No

If yes, please list the company and amount.

*Will the applied for policy replace any of the above listed policies?

Yes
No

If yes, which policy?

And what is the purpose of the replacement?

*Please indicate the name of your personal physician.

*Please provide their details here.

This includes their address and phone number.

*Please indicate the date you last saw them.

*Please indicate the reason for the appointment and the diagnosis.

*Please indicate your height and weight.

Please ensure that this is as accurate as possible.

*Have you experienced any weight change in the Past Year of 10 lbs. or Greater?

Yes
No

*Do you or have you ever used tobacco or nicotine products in any form?

Yes
No

*Please list all current medications and doses.

*Have you visited any other medical practitioners or specialists in the past 5 years?

Yes
No

*Please provide details regarding your father.

Please indicate his age (if living), his health status and, if deceased, his age at death and the cause of death.

*Please provide details regarding your mother.

Please indicate her age (if living), her health status and, if deceased, her age at death and the cause of death.

*Please provide details regarding your sibling(s).

If you have siblings, on separate lines, please indicate their ages (if living), their health status and, if deceased, their ages at death and the causes of death.

*Does the insured plan on traveling outside the country within the next year?

Yes
No

*Within the past three years has the Proposed Insured participated in/planned to participate in any dangerous activities?

For example, underwater sports (scuba diving, skin diving, etc…), racing sports, sky sports, rock climbing, etc.

Yes
No

*Has the proposed insured had any motor vehicle tickets within the past 5 years?

Yes
No

*Do you exercise regularly?

Yes
No

*Does the proposed insured have any past or present health conditions that we should know about?

Please let us know of anything, no matter how minor.