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Life Insurance Intake Form

Life Insurance Intake Form

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1. CLIENT INFORMATION

Full Name

First Middle Last

Date of Birth

MM slash DD slash YYYY

Age

Gender

Male

Female

Marital Status

Single

Married

Divorced

Widowed

Phone

Email

Best Time to Contact

Morning

Afternoon

Evening

Preferred Contact Method:

Phone

Text

Email

Mailing Address

Street Address City State / Province / Region ZIP / Postal Code Country

2. COVERAGE INFORMATION

How much life insurance are you looking for?

$100,000

$250,000

$500,000

$1,000,000

Other

Coverage Type (if known):

Term Life

Whole Life

Universal Life

Not Sure

Desired Term (if applicable):

10 Years

15 Years

20 Years

30 Years

Unsure

3. BASIC HEALTH INFORMATION

Height (ft. or in.)

Weight (lbs.)

Do you currently use any of the following?

Tobacco

Nicotine Vape

Cigars

None

If yes, please explain:

Have you been diagnosed with or treated for any of the following?

Diabetes

Heart Disease

High Blood Pressure

High Cholesterol

Cancer

Sleep Apnea

None

Other (please explain):

4. OCCUPATION & LIFESTYLE

Occupation

Employer

Type of Work (office, field, etc.):

Do you participate in any hazardous activities?

Aviation

Scuba Diving

Racing

Mountain Climbing

None

Other

5. FAMILY INFORMATION

Number of Children:

Ages of Children:

Who would be your primary beneficiary?

Untitled

6. EXISTING COVERAGE

Do you currently have life insurance?

Yes

No

Not Sure

If Yes, Carrier:

If Yes, Amount: $

Do you have life insurance through your employer?

Yes

No

Not Sure

If yes, approximate amount: $

7. ADDITIONAL INFORMATION

Please share any other information that may help us provide you with the best options:

8. PINK INSURANCE USE ONLY

Lead Source:

Newsletter

Website

QR Code

Referral

Walk-In

Existing Client

Other

Agent Assigned

Date Received:

Follow-up Date:

Notes:

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First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

What type of insurance are you looking for?

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