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

PAGE #1

CLIENT INFORMATION #1

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 12 months have you used any form of tobacco?
Have you tested positive for HIV/AIDS or been diagnosed with a terminal illness? Are you bedridden, hospitalized, or need help with daily living like bathing, eating, or dressing?
Heart disease, attack, surgery, or failure? Stroke, aneurysm, seizures, lupus, or cancer? Lung disease, COPD, or oxygen use?
Any Liver, kidney issues, or dialysis? Diabetes with complications, neuropathy, or hepatitis b/c or organ transplants?
Any alcohol/drug abuse, DUI, felonies or parole? Depression, bipolar, schizophrenia, memory loss, Alzheimer’s, or dementia?

Insert conditions in "Health Conditions & Meds"

Are you retired or still working? *

List the Clients Health Conditions & Medications *

▪️ NOTE: Insert the clients diagnose dates and treatment dates

PAGE #2

THREE OPTION WORKSHEET

Premiums NEVER increase. Benefits NEVER decrease.

PERMANENT COVERAGE that protects you your whole life.

You’re PROTECTED from THE FIRST DAY your policy is in effect.

Policy NEVER EXPIRES or cancels (as long as premiums are paid).

Coverage CAN NOT BE CANCELLED due to age or health changes.

BENEFITS PAY OUT within a 24-72 hours upon claim approval.

If the client doesn't qualify for preferred or standard (day one) coverage, ignore the 1st benefit mentioned above

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

Monthly Draft Date

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!