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Section 1: Personal Information

(This helps us identify and communicate with you.)

Full Name *

Date of birth *

Street Address *

City

State

Country

Postal code

Phone *

Email *

Section 2: Financial Information

(This helps us determine the best policy structure for your financial situation.)

Annual Income *

*(Approximate amount, used to align your policy with your financial goals)*

Occupation *

*(For risk assessment and understanding your insurance needs.)*

What are your main financial goals with this policy?

Retirement savings

Tax-free income

Estate planning

Wealth protection

Other:

Section 3: Health Information

(Your health helps determine eligibility and premiums. All information remains confidential.)

Note: Some of these questions may require a brief medical exam, but rest assured, all personal health information is protected by law.

Do you currently take any medications? *

Yes

*(If yes, please provide general details.)*

Do you use tobacco products? *

Yes

*(This affects premium rates.)*

Do you engage in any high-risk activities (e.g., skydiving, scuba diving, etc.)? *

Yes

*(This helps us assess risk levels.)*

Section 4: Insurance Preferences

(Your answers will help us tailor the policy to your needs.)

Desired Coverage Amount (Death Benefit): *

Less than $100,000

$100,000 - $500,000

$500,000 - $1,000,000

Over $1,000,000

Preferred Premium Payment Schedule: *

Monthly

Quarterly

Annually

Do you have any existing life insurance policies? *

Yes

If yes, what type?

Section 5: Beneficiary Information

(This information is used to make sure the right people benefit from your policy.)

Primary Beneficiary Name & Relationship to You: *

*(Who would receive the benefit in case of your passing.)*

Contingent Beneficiary Name & Relationship: *

*(Optional: Who would receive the benefit if the primary beneficiary is unavailable.)*

Section 6: Additional Options (Optional)

(You can add extra benefits or riders to your policy.)

Would you like to include any of the following riders?

Long-Term Care

Waiver of Premium

Accelerated Death Benefit

Other:

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