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Name: |
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Street Address: |
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Town: |
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State: |
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ZIP: |
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| Insured's Date of Birth: |
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| POLICY TYPE: |
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| What type of policy are you looking for? |
Term - 10 Year |
Term - 30 Year |
| (Check all that apply) |
Term - 20 Year |
Universal Life (Permanent) |
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| Face Amount of Policy (How
much?): |
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| NEEDS ANALYSIS: |
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| What is the
main reason you are looking for life insurance right now? |
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| What is your
main concern when purchasing a life insurance policy?
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| Do you own a home? |
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| What is the balance on
your mortgage(s)? |
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| How many years
do you have left on your mortgage(s)? |
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| How much can you afford to
set aside per month for life insurance premiums? |
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| How many children do you
have? |
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| What is your approximate
net worth? |
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| About how much does your
family have in outstanding debt aside from your mortgage? |
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| What is your annual
income? |
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| UNDERWRITING
INFORMATION: |
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| Date of Birth: |
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| Smoker or Non-Smoker: |
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| Height: |
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| Weight: |
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| Do you or have you at any time in your
life |
AIDS |
Asthma |
| suffered from any of the
following? |
High Cholesterol |
High Blood Pressure |
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Chrones |
Strokes |
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Heart Attacks |
Cancer |
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Diabetes |
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| Do you have any other health problems or
conditions? |
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| Please provide details
concerning any health problems, conditions, etc. Include treatment,
severity, age of onset, date of remission, etc.: |
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| Are you on medication? |
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| If so, which medication and what is your
dosage? |
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| Any family history of illness
or disease? |
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| If so, please provide details: |
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| Contact's Phone Number (Include Area
Code): |
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Contact's Fax Number (Include Area Code): |
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Contact's E-Mail Address: |
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