Static.helpjuice.com View List Drivers Download › Url: https://static.helpjuice.com/helpjuice production/uploads/upload/image/6503/direct/1592334238110-CG CLIENT One-Page Intake Form Fillable
Proposed Insured Information: All Fields Are Required Insured Name: State of Residence: DOB: Gender: Marital Status: One-Page Intake Form Proposed Insured Client Birth Country/State: Social Security #: City: Driver's License State: Driver's License #: Address: State: Zip: Driver's Licenses Exp. Date: Best time to contact client: c AM c PM Preferred phone number for contact: Proposed insured email address: Tobacco Usage: c Yes c No If yes, indicate type of tobacco and last date of use: Has the proposed insured ever been treated for the following? Cancer, Diabetes, Heart Disease, Stroke? If yes, indicate date of diagnosis: Have you ever been declined, rated or postponed for life or health insurance? c Yes c No Employment and Income Information Is the proposed insured currently employed? c Yes c No Annual Income: Estimated Total Assets: Employer: Estimated Total Liabilities: c Yes c No Job Title: Net Worth: Owner and Beneficiary Information Owner Name: Social Security # / Tax ID: If insured is the not owner, please complete: Owner is a c Person c Trust c Corporation c Other__________________________ If owner is a corporation, please complete: Name of Officer: Officer Title: Officer Phone Number: Owner Address: Officer Email Address: City: State: Zip: Relationship to proposed insured: Primary Beneficiary Name: Primary / Contingent Beneficiary Name: Contingent Beneficiary Name: Owner DOB or Trust Date: SSN or TAX ID: Relationship: SSN or TAX ID: Relationship: SSN or TAX ID: Relationship: Percent: Percent: Percent: %DOB: %DOB: %DOB: Replacement Information Does the proposed insured currently own any life insurance? c Yes No If NYeos, is this policy replacing any existing coverage? c Yes c No Does the owner currently own other any life insurance? c Yes c No If proposed insured or owner has existing coverage, provide insurance company name(s), death benefit(s), policy number(s), policy issue date(s), and type of policy (term or permanent): Fax completed form to Charlie Anderson: 952-653-1100 or email to canderson@christensengroup.com Christensen Group9855 West 78th Street, Suite 100Eden Prairie,MN 55344952-653-1048www.christensengroup.comMicrosoft Excel 2019