Life Ins. Intake Form | Financial Advantage Consultants

Sergio Rodriguez

Financial Advantage Consultants

[email protected]

(956) 624-2000

Life Insurance Intake Form

Name

First Name *

Middle Name

Last Name *

Address

Street Address *

Apartment/Suite/Unit Number

City *

State *

Postal code *

Previous Address (if lived at current address for less than 5 years)

Contact Information

Phone *

Email *

Personal Information

Date of Birth *

Place of Birth *

SSN / TIN *

Driver's License State *

Driver's License Number *

Marital Status *

Single
Married
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Are you currently an active duty service member? *

Yes
No
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Medical Information

Height *

Weight *

Do you use Nicotine? *

Please list any medical conditions or health issues: *

Please list all medications (prescription drugs) that you are currently taking. *

Have you been admitted to a hospital in the past 12 months? If so, please explain.

Please list the names and addresses of your primary care physician and any specialists you are currently seeing. *

Are both your parents still alive? If so, what are their ages? If not, at what age did they pass away and cause of death?

Beneficiary Details

Primary Beneficiaries (Required Info: Name, Address, Phone, Date of Birth, Percentage of Benefit, Relationship to Policyholder) *

Contingent Beneficiaries (Required Info: Name, Address, Phone, Date of Birth, Percentage of Benefit, Relationship to Policyholder) *

Financials

Monthly Household Expenses *

Individual Annual Income *

Household Annual Income *

Total Liquid Assets (Checking, Savings, Investments) *

Total Real Estate Assets (Homes, Land, Commercial Property) *

Employment

Employer Name *

Employer Phone *

Employer Address *

Please provide a brief description of your current occupation or job role. *

How long have you been employed at your current job? *

Bank Information For Premium

Preferred Draft Date (e.g., 1st of the month, 15th of the month) *

Bank Name *

Account Holder Name *

Account Type *

Checking
Savings
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Account Number *

Routing Number *

Signature

I choose to apply for this life insurance coverage/policy. Please submit my application through the online application process for me using the information I have provided. I attest that all the information give was accurate and true.

Please sign in the box.

Signature *

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