Life Insurance Quote Worksheet

The person to be insured

Full legal name

Date of birth

State / country of birth

Height

Weight

Gender

U.S. citizen / resident?

Occupation

Employer

Annual income

Coverage & health

Coverage amount wanted

Main purpose (income, mortgage, final expenses, legacy…)

Coverage type

Tobacco use

Tobacco details (type, frequency, quit date)

Medical conditions, surgeries and hospital stays (condition, when, current status)

Current medications (name, dose, what it treats)

Primary doctor — name and city

Last doctor visit (date / reason)

Family history — parents / siblings: heart disease, cancer, diabetes; age and cause of death if deceased

Any of these apply? Treated for alcohol / drug use DUI or license suspension Hazardous hobbies (aviation, racing, diving) Foreign travel planned Military service Bankruptcy (past or pending)

Details for anything checked above

Existing coverage & beneficiaries

Existing life insurer (if any)

Existing — term or permanent

Existing face amount

Existing policy year started

Existing premium

Replace it, keep it, or undecided?

Primary beneficiary 1 — full name

Primary beneficiary 1 — relationship & share %

Primary beneficiary 2 — full name

Primary beneficiary 2 — relationship & share %

Contingent beneficiary 1 — full name

Contingent beneficiary 1 — relationship & share %

Contingent beneficiary 2 — full name

Contingent beneficiary 2 — relationship & share %

If a beneficiary is a minor — who should manage the money for them, and until what age?

Mortgage balance

Other debts

Years of income to replace

Spouse / partner income

Savings & investments (approx.)

College funding wanted?

Anything else — health worries, budget for premium, questions

Where should we send your quote?

First name

Last name

Email

Phone

Health answers are used only to place you with the right insurer and rate class. Final rates are set by the insurer after underwriting, which may include a medical exam or records review. Never enter a Social Security number — we will never ask for one here.

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The person to be insured

Coverage & health

Existing coverage & beneficiaries

Where should we send your quote?

Worksheet received.