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Agent Info:
Name
:
Victoria Adgett
License ID
:
3659421
Phone
:
(775) 800-9545
Email
:
[email protected]
Address
:
3115 Knight Road, Reno, Nevada, 89509
Life
Applicant
Medical History
Carrier
Coverage
Finish
Applicant
Applicant
First Name *
Last Name *
Date of Birth *
Marital Status
Single
Married
Widowed
Separated
Gender
Male
Female
Beneficiary
First Name
Last Name
Relationship (with Insured)
Contingent Beneficiary
Residency
Address *
City *
State *
Alaska
Alabama
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zipcode *
Do you own your home?
Yes
No
Mortgage
Do you have mortgage?
Yes
No
How much do you owe?
Are you a U.S. citizen or permanent resident?
Yes
No
What type of visa or residency status?
Email *
Phone *
Employment & Income
Occupation *
Annual income *
How many dependents rely on your income?
Employer name
Length of employment
Please fill all the mandatory questions.
Next
Next
Medical History
Personal
Height (ft) *
Height (inches) *
Weight (lbs) *
Have you had a life insurance medical exam denied or postponed?
Yes
No
Please explain
Health
Any hospitalizations in the last 5 years? *
Yes
No
Please explain
Tobacco Usage *
None
Cigarettes
Cigar
Chewing Tobacco
Other
Heart Disease? *
Yes
No
Cancer? *
Yes
No
Any parent/sibling with heart disease or cancer before age 60? *
Yes
No
Diabetes? *
Yes
No
High blood pressure? *
Yes
No
High cholesterol? *
Yes
No
Depression / anxiety / bipolar diagnosis? *
Yes
No
Please explain
Drug or alcohol abuse treatment? *
Yes
No
Please explain
DUI in the past 5 years? *
Yes
No
Please explain
Any other notable diagnosis you have been treated for?
Yes
No
What diagnosis would that be
Notable Diagnosis *
Additional Information (Extreme sports, hazardous activities, etc.):
Taking Medications?
Yes
No
Medication
1
Medications
Medication Name
Reason for taking
When Diagnosed
Frequency (How often do you take medication)
Amount Taken Each Dosage
Remove Medication
Add Medication
Activities
Aviation pilot?
Yes
No
Scuba diving?
Yes
No
Rock climbing?
Yes
No
Skydiving?
Yes
No
Motorsports?
Yes
No
Any felony conviction in the past 10 years?
Yes
No
Please explain
Please fill all the mandatory questions.
Next
Next
Carrier
Are you currently insured? *
Yes
No
How many policies do you currently have? *
1
2
3
4
5
Policy
1
Are you looking to:
Replace
Add
New
Please tell us about your current insurance
Current Life Insurance Carrier
Enter Other Carrier Name *
Policy Type
Term
Whole Life
Other
Preferred term length?
10 years
15 years
20 years
25 years
30 years
35 years
Specify Policy
Limit
Remove Policy
Add Policy
Has any life insurance company denied or rated you in the past?
Yes
No
Please explain
Have you had a policy lapse within the last 3 years?
Yes
No
Reason for getting this life insurance
Buy Sell Agreement
Estate Planning
Family Protection
Future Needs
Mortage Protection
Partnership
Retirement
Trust
Other
Specify Reason
Please fill all the mandatory questions.
Next
Next
Coverage
Type of Life Insurance you wish to avail?
Life Insurance
Long Term Care
Retirement Planning and Financial Planning
How much Life Insurance are you looking to get?
Sub Type Life Insurance
Term Life Insurance
Whole Life Insurance
Universal Life Insurance
Variable Life Insurance
Indexed Universal Life Insurance
Survivor Life Insurance (also know as Second to die policies)
Sub Type Long Term Care
Traditional Long Term Care
Hybrid Long Term Care and Life Insurance
Sub Type Retirement Planning and Financial Planning
Traditional IRA
Roth IRA
Group 401k Plans (for businesses)
Solo 401k
SEP IRA (Simplified Employee Pension Plan)
Simple IRA
Investment Advisory
Brokerage
Education Saving Plans (commonly known as 529 plans)
Annuities
Guaranteed Income Vehicles
Specify type of life insurance
What is your monthly budget?
< $100
$100 - $500
$501 - $1,000
> $1,000
Payment Sequence
Monthly
Quarterly
Semi-annual
Annual (discounted)
Do you want a medical exam or no exam?
No Exam (Simplified Issue)
Fully Underwritten (best pricing)
Interested in a policy that converts to permanent insurance later?
Yes
No
You’re interested in as supplemental coverages
Critical Illness Insurance
Cancer Policy
Disability Income Insurance
Accidental Death Insurance
Long-Term Care / Hybrid Life + LTC
Mortgage Protection Life
Final Expense (if they choose Term or UL)
Do you have a spouse?
Yes
No
Expenses
Funeral and Other Final Expense
Client
Spouse
Mortgage
Client
Spouse
Other outstanding Debts
Client
Spouse
College costs
Child
1
Annual Amount
Number of Years in College
Total Cost
Remove Child
Add Child
Total capital needed for college
Client
Spouse
Income
Annual before-tax income your family would need if you died today
Client
Spouse
Annual income available to your family from other sources
Client
Spouse
Annual income to be replaced
Client
Spouse
Capital needed for income
Years Income Needed
10 years
15 years
20 years
25 years
30 years
35 years
40 years
45 years
50 years
Client
Spouse
Total capital required
Client
Spouse
Assets
Savings and investments
Client
Spouse
Retirement savings
Client
Spouse
Present amount of life insurance
Client
Spouse
Total of all assets
Client
Spouse
Estimated amount of additional life insurance needed
Client
Spouse
Please fill all the mandatory questions.
Submit
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