CLIENT WORKSHEET

Fill out the form to get the best rates for your client.

Use different emails and phone numbers if submitting both forms.

PROPOSED INSURED #1

PROPOSED INSURED #2

PAGE #1

CLIENT INFORMATION #1

HEALTH QUESTIONS

Have you ever been diagnosed with any of the following:

  1. In the past 12 months have you used any form of tobacco?

  2. Have you tested positive for HIV/AIDS or been diagnosed with a terminal illness? Are you bedridden, hospitalized, or need help with daily living like bathing, eating, or dressing?

  3. Heart disease, attack, surgery, or failure? Stroke, aneurysm, seizures, lupus, or cancer? Lung disease, COPD, or oxygen use?

  4. Any Liver, kidney issues, or dialysis? Diabetes with complications, neuropathy, or hepatitis b/c or organ transplants?

  5. Any alcohol/drug abuse, DUI, felonies or parole? Depression, bipolar, schizophrenia, memory loss, Alzheimer’s, or dementia?

Insert conditions in "Health Conditions & Meds"

▪️ NOTE: Insert the clients diagnose dates and treatment dates

PAGE #2

THREE OPTION WORKSHEET

Premiums NEVER increase. Benefits NEVER decrease.

PERMANENT COVERAGE that protects you your whole life.

You’re PROTECTED from THE FIRST DAY your policy is in effect.

Policy NEVER EXPIRES or cancels (as long as premiums are paid).

Coverage CAN NOT BE CANCELLED due to age or health changes.

BENEFITS PAY OUT within a 24-72 hours upon claim approval.

If the client doesn't qualify for preferred or standard (day one) coverage, ignore the 1st benefit mentioned above

$

BENEFICIARY SECTION

PRE-QUALIFYING WORKSHEET

Q: "What is the best address to mail the policy to?"

PROPOSED INSURED SECTION

Q: They need to verify your identity, what is your drivers license #?
Q: They are going to run your MIB report to see if your eligible, whats your social?

PLAN & PAYMENT INFO

Q: Upon approval when do you want your policy to start?
$

NOTES:

Begin the application process with your selected life insurance carrier. Keep the client on the phone as you submit!

NEXT

Showing 1 of 3

PAGE #1

CLIENT INFORMATION #2

HEALTH QUESTIONS

Have you ever been diagnosed with any of the following:

  1. In the past twelve (12) months, has the applicant used any form of tobacco?

  2. Has the applicant tested positive for HIV or been diagnosed by a physician as having AIDs or a life expectancy of twelve (12) months or less? Is the applicant currently bedridden, hospitalized, in a care facility, or receiving hospice care? Receive assistance with daily living activities such as taking medications, bathing, toileting, dressing, or eating?

  3. Disease of the heart, including heart attack, heart surgery or congestive heart failure? Disease of the circulatory system, including stroke, aneurysm, seizure, lupus, sickle cell anemia or been advised to have surgery to improve circulation? Any Cancer, other than basal cell skin cancer?

  4. Disease of the lungs, including COPD, chronic asthma or the use of oxygen, nebulizers or nitroglycerin? Any Disease of the liver or kidney, including insulin dependent diabetes, Hepatitis B or C, or had an organ transplant? Complications of diabetes, such as amputation, diabetic coma, blindness, neuropathy or kidney disorder?

  5. In the past twelve (12) months, has the applicant been confined to a hospital more than twice or had any surgeries? Recommended to have counseling for alcohol, drug abuse, convicted of a DUI, felony or on parole?

  6. Depression, bipolar disorder, schizophrenia, or memory loss including Alzheimer’s, dementia or ALS (Lou Gehrig’s disease)?

Insert conditions in "Health Conditions & Meds"

▪️ NOTE: Insert the clients diagnose dates and treatment dates

PAGE #2

$

BENEFICIARY SECTION

PRE-QUALIFYING WORKSHEET

Q: "What is the best address to mail the policy to?"

PROPOSED INSURED SECTION

Q: They need to verify your identity, what is your drivers license #?
Q: They are going to run your MIB report to see if your eligible, whats your social?

PLAN & PAYMENT INFO

Q: Upon approval when do you want your policy to start?
$

NOTES:

Begin the application process with your selected life insurance carrier. Keep the client on the phone as you submit!

NEXT

Showing 1 of 3