Confidential Questionnaire for Variable Life Insurance

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Insured Information

First Name

Enter your first name

Middle Initial

Last Name

Enter your last name

Have you changed your name in the last 5 years?

Previous Full Name:

Gender

Your Email

Enter best email for form submission confirmation.

Social Security Number

Date of Birth

Enter as MM/DD/YYYY or select from calendar

Place of Birth

State, Country

Are you a US citizen?

What country are you a citizen of?

Do you have a Visa or Green Card?

What type of Visa?

Drivers License Number

Drivers License State

Expiration Date

Marital Status

Spouse's First Name

Middle Initial

Spouse's Last Name

Spouse's Date of Birth

Spouse's Place of Birth

State, Country

Spouse's Social Security Number

Home Street Address

City

State

Zip Code

How long have you lived at this address?

Previous Address:

Preferred Phone Number

Do you want to opt-in to receive text messages?

Employment Information

Occupation

State your occupation.

Nature of Duties

Indicate what you do at your current position.

Employer

Business Address

Business Phone

Years of Employment

Previous Employer

Are you employed by FINRA or affiliated with any entity regulated by FINRA, or employed by a securities exchanged or affiliated with an entity regulated by a securities exchange?

Are you a director, 10% shareholder, or a policy-making officer of a publicly traded company?

What is the Company Name and Trading Symbol?

Health Information

Height

Enter as 5' 10"

Weight

Enter as a number (e.g. 185)

Last (or current) Blood Pressure Reading (if known)

Example: 140/90

Please indicate your Diabetes doctor, treatment, medication, and date of onset

Please indicate your Cancer type, doctor, treatment, medication, and date of onset

Please indicate your stroke treatment, medication, and date of onset

Please indicate your Lupus / Autoimmune disease doctor, treatment, medication, and date of onset

Please indicate your COPD / Emphysema doctor, treatment, medication, and date of onset

Please indicate your Coronary Artery Disease doctor, treatment, medication, and date of onset

Please indicate your Ulcerative Colitis doctor, treatment, medication, and date of onset

Please indicate your Fatty Liver doctor, treatment, medication, and date of onset

Please indicate your Hepatitis variation, doctor, treatment, medication, and date of onset

Please indicate your Rheumatoid Arthritis doctor, treatment, medication, and date of onset

Please indicate your Atrial Fibrillation doctor, treatment, medication, and date of onset

Please indicate your Bipolar Disorder doctor, treatment, medication, and date of onset

Please indicate your Cardiomyopathy doctor, treatment, medication, and date of onset

Please indicate your Elevated Cholesterol date of onset

Please indicate your Crohn's Disease doctor, treatment, medication, and date of onset

Please indicate your Gastric Bypass / Lap Band doctor, treatment, medication, and date of onset

Please indicate your Epilepsy / Seizure doctor, treatment, medication, and date of onset

Please indicate your Kidney Disease doctor, treatment, medication, and date of onset

Please indicate your Multiple Sclerosis (MS) doctor, treatment, medication, and date of onset

Please indicate your Muscular Dystrophy doctor, treatment, medication, and date of onset

Please indicate your Parkinson's Disease doctor, treatment, medication, and date of onset

Please indicate your Narcotic medications and date of starting use

Please indicate your Peripheral Artery Disease / Peripheral Vascular Disease doctor, treatment, medication, and date of onset

Please indicate your Dementia / Alzheimer's doctor, treatment, medication, and date of onset

Please indicate your Barrett's Esophagus doctor, treatment, medication, and date of onset

Please indicate your Cardiovascular Disease doctor, treatment, medication, and date of onset

Please indicate your AIDS / HIV doctor, treatment, medication, and date of onset

Please provide how you use marijuana (ingest, vaporize, or inhale), frequency of use, and purpose (medicinal or recreational)

What hazardous activities do you partake in and how often?

What exercise program and how often?

Where and when have you traveled or plan to travel abroad?

How many drinks do you have per week?

Life Insurance Information

Do you currently have life insurance?

How many policies do you have?

Policy 1: Insurance company, date of issue, amount of coverage, and business or personal

Policy 2: Insurance company, date of issue, amount of coverage, and business or personal

Policy 3: Insurance company, date of issue, amount of coverage, and business or personal

Have you ever sold or settled a policy?

Please indicate the insurance company, date of sale and amount of coverage

Financial Information

Investment Experience

	0 Years	1-5 Years	6-10 Years	10+ Years
Equities (and Mutual Funds, ETFs)
Fixed Income (and Mutual Funds, ETFs)
Variable Annuities
Variable Life Insurance
Fixed Life/Annuities
Options
Private Placements/Alternative Investments
Cash/Cash Equivalents

	Existing Assets ($)
Equities (and Mutual Funds, ETFs)
Fixed Income (and Mutual Funds, ETFs)
Variable Annuities
Variable Life Insurance
Fixed Life/Annuities
Options
Private Placements/Alternative Investments
Cash/Cash Equivalents

Federal Tax Bracket

Net Worth (Excluding Primary Residence)

Approximate Net Worth (Excluding Primary Residence)

Liquid Net Worth (Convertible to Cash Within 5 Days)

Approximate Liquid Net Worth

Annual Household Income

Approximate Annual Household Income

Total Net Worth

Total Assets

Total Liabilities

Are you or anyone with an interest in this account either a senior military, governmental or political official in non-US country, or closely associated with one, or are you an immediate family member of such an official?

Identify the name of the official, office held, and country

Who is the Inheritance/Gift from?

Explain source of funds

Beneficiary Information

Will the beneficiary be an individual, trust, or corporation?

Corporation Name

Corporation Tax ID

Corporation Address

City

State

Zip Code

Corporation Phone Number

Trust name

Trust Date

Trustee

Tax ID

Trust Address

City

State

Zip Code

How many beneficiaries will you have on your policy?

Beneficiary 1: First Name

Last Name

What is their relationship to you?

Example: spouse, child, etc.

Date of Birth

Phone Number

Social Security Number

Email Address

Street Address

City

State

Zip Code

Beneficiary 2: First Name

Last Name

What is their relationship to you?

Date of Birth

Phone Number

Social Security Number

Email Address

Street Address

City

State

Zip Code

Beneficiary 3: First Name

Last Name

What is their relationship to you?

Date of Birth

Phone Number

Social Security Number

Email Address

Street Address

City

State

Zip Code

Beneficiary 4: First Name

Last Name

What is their relationship to you?

Date of Birth

Phone Number

Social Security Number

Email Address

Street Address

City

State

Zip Code

Beneficiary 5: First Name

Last Name

What is their relationship to you?

Date of Birth

Phone Number

Social Security Number

Email Address

Street Address

City

State

Zip Code

Will there be any contingent beneficiaries that are trusts?

Trust Name

Trust Date

Trustee

Trust Tax ID

Trust Address

City

State

Zip Code

Will there be any contingent beneficiaries that are individuals?

How many contingent beneficiaries that are individuals?

Contingent Beneficiary 1: First Name

Last Name

What is their relationship to you?

Date of Birth

Social Security Number

Email Address

Phone Number

Street Address

City

State

Zip Code

Contingent Beneficiary 2: First Name

Last Name

What is their relationship to you?

Date of Birth

Social Security Number

Email Address

Phone Number

Street Address

City

State

Zip Code

Contingent Beneficiary 3: First Name

Last Name

What is their relationship to you?

Date of Birth

Social Security Number

Email Address

Phone Number

Street Address

City

State

Zip Code

Contingent Beneficiary 4: First Name

Last Name

What is their relationship to you?

Date of Birth

Social Security Number

Email Address

Phone Number

Street Address

City

State

Zip Code

Contingent Beneficiary 5: First Name

Last Name

What is their relationship to you?

Date of Birth

Social Security Number

Email Address

Phone Number

Street Address

City

State

Zip Code

Will you be the owner?

Will the owner be a trust?

Will the owner be a Corporation?

Corporation Name

Corporation Tax ID

Corporation Address

City

State

Zip Code

Corporation Phone Number

Trust name

Trust Date

Trustee

Tax ID

Trust Address

City

State

Zip Code

How many individual Owners?

Owner 1: First Name

Last Name

What is their relationship to you?

Date of Birth

Social Security Number

Email Address

Street Address

City

State

Zip Code

Owner 2: First Name

Last Name

What is their relationship to you?

Date of Birth

Social Security Number

Email Address

Street Address

City

State

Zip Code

Owner 3: First Name

Last Name

What is their relationship to you?

Date of Birth

Social Security Number

Email Address

Street Address

City

State

Zip Code