Life Questionnaire
In order to find the very best plan for you and your needs, please answer the following questions honestly and completely. I will never share or sell your information and you can find our privacy policy here. If you have any questions, please let me know.

My service is always completely free to you and you are under no obligation to purchase a policy from me. But if you do, you will only have to pay your premiums and any applicable application fees for your plan. 
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Email *
Address (Ex: 123 Insure Me Lane, Coverage NC 54321) *
Phone number *
Please provide the following for EACH person you want to include on your policy:

1. FULL legal name
2. Relationship
3. Date of birth AND age

(Ex. Mary Jane Doe, self, 01/01/1971, 51)
Please provide the height and weight of any adults listed above. (Ex. Mary 5'5, 145) *
Any tobacco use in the past 12 months by any adult listed above? *
If yes to tobacco use, please indicate which adult(s).  
Please list the following for ALL applicants: 

1. All health conditions
2. Year of diagnosis
3. Recommended course of treatment

If none, please respond "N/A". 

(Ex. Mary- Type 2 Diabetes, 2019 - pills, diet, exercise)

Be mindful! The carrier may not require a medical exam but they will check the medical information bureau (MIB) and run a prescription history check. 
Please list the following for ALL applicants:

1. Name and dosage of all CURRENT prescription medications
2. Year of first fill

If none, please respond "N/A".  

(Ex. Mary-metformin, 500 mg, 2x day, 2019)

Be mindful! The carrier may not require a medical exam but they will check the medical information bureau (MIB) and run a prescription history check. 
In the past six (6) months, has any applicant tested positive for COVID? If yes, please provide the date that you were negative or symptom free.  *
Please select any of the following that applies to any applicant. 
Please list the name, address and phone number of the current primary health care provider for each applicant? *
What are your life insurance expectations? Please check all that apply. *
If you're only looking for enough coverage to take care of your final expenses, are you interested in a traditional funeral or a cremation? 

The average cost of a traditional funeral can vary from $8,000 to $14,000 and the average cost of a cremation can vary from $1500 to $7000. Call your local funeral home or crematorium for rates in your area.
Are there any additional premium riders that you would like to include? Please check all that apply. *Riders are additional benefits that can be added to your policy to customize it to your needs.
How much can you comfortably afford to pay each month for your life insurance coverage? This will provide our budget guideline as I build your policy. *
How would you like to pay your premiums each month? *
Would this coverage replace any existing coverage? *
Desired start date for coverage? 

Please note that coverage will begin when your first premium is paid.
Are you or anyone on your application a Veteran? *
Any questions or concerns you would like me to address? *
Once I build a plan for you, what is the best day and time to reach out to you to go over your options? *
Would you like to answer more medical questions at this time or wait until our appointment?  *
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