Client Information
Name
First Name
Last Name
Middle Name
Email
example@example.com
Phone Number
Primary Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long at this address?
Birth Date
-
Month
-
Day
Year
Place of Birth
Height
Weight
Gender
Male
Female
SSN
Driver's License (please text/email/upload me a photo or copy of your driver's license)
Driver's License Expiry date
-
Month
-
Day
Year
US Citizen
No
Yes
How long in the country?
Date of Entry in USA? (Can be found on the passport)
Type of Visa (Important: Please email or upload a copy of your work visa eg. I-797A, I-40 etc)
Resident Alien
Green Card
Permanent Resident
Work Visa
Other
Select one
Smoker
Non-Smoker
Status select one
Single
Married
Separated
Divorced
Widow
Employment Information
Employer Name
Employer's Phone Number
Employer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long at this Employer?
Occupation
Job Title
Gross Annual Income
Net Worth
Doctor's Information
Primary Doctor's name
Primary Doctor's Phone Number
Primary Doctor's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Any Medical Condition?
*
Medications
*
Last Date Visit
*
Reason of last doctor's visit?
*
Result
*
Kaiser Patient
Yes
No
Beneficiary Information
Beneficiary1 Name
First Name
Last Name
Beneficiary1's Middle Name
Beneficiary1's Phone Number
Beneficiary1's SSN
Beneficiary1's Date of birth
-
Month
-
Day
Year
Beneficiary1's Relationship
Beneficiary1's Percentage
Beneficiary2's Name
First Name
Last Name
Beneficiary2's Middle Name
Beneficiary2's Phone Number
Beneficiary2's SSN
Beneficiary2's Date of Birth
-
Month
-
Day
Year
Beneficiary2's Relationship
Beneficiary2's Percentage
Field Underwriting
WITHIN THE PAST FIVE YEARS HAVE YOU USED NICOTINE IN ANY FORM?HAVE YOU EVER USED OR EXPERIMENTED WITH MARIJUANA?
HAVE YOU EVER HAD OR BEEN DIAGNOSED WITH OR TREATED FOR MAJOR MEDICAL ISSUE(S): If yes, please explain.ISSUES SUCH AS: STROKE, HIGH BLOOD PRESSURE, HEART ATTACK, DIABETES, THYROID, SLEEPAPNEA, HEART ISSUE, ANXIETY, DEPRESSION, SURGERY, ETC.
HAVE YOU EVER HAD OR BEEN DIAGNOSED WITH OR TREATED FOR MINOR MEDICAL ISSUE(S): If yes, please explain.
DO YOU TAKE ANY MEDICATIONS REGULARLY, INCLUDING OVER-THE-COUNTER MEDICATIONS. If yes, give the name of the medication(s), dose & frequency.
DO YOU DRINK ALCOHOLIC BEVERAGES? If yes, provide type, frequency & amount.DO YOU TAKE PROTEIN SUPPLEMENTS? If yes, provide type, frequency & amount.
ANY FELONIES, MISDEMEANORS, DUI(s) or LICENSE SUSPENSION EVER? If yes, please explain.
DO YOU PLAN TO TRAVEL OUTSIDE OF THE UNITED STATES WITHIN THE NEXT YEAR? If yes, where?
Signature
Submit
Should be Empty: