Full Name

Name (Beneficiary)

Birthday

Birthday (Beneficiary)

Age

Age (Beneficiary)

Mortgage Info

Mortgage Amount

Purchase or Refinance Purchase or Refinance Purchase Refinance Line of Credit Other

Is that a 30 year term? Is that a 30 year term? 30 20 15 Other

What's the monthly payment with insurance, taxes, interest, all together?

Do you know what your home is currently worth?

So what was the main concern when you filled out this form?

Medical Information

Height

Height (Beneficiary)

Weight

Weight (Beneficiary)

Any prescribed medications in the last 5-10 years?

Prescriptions (Beneficiary)

Smoker or non-smoker? Smoker or non-smoker? Smoker Non-smoker

Smoker or non-smoker? (Be) Smoker or non-smoker? (Be) Smoker Non-smoker

Heart Problems Heart Problems Yes No

Heart Problems (Be) Heart Problems (Be) Yes No

What was your specific medical condition?

What was your specific medical condition? (Beneficiary)

And when was that?

And when was that? (Beneficiary)

Any prescribed meds for that?

Any prescribed meds for that? (Beneficiary)

High Blood Pressure High Blood Pressure Yes No

High Blood Pressure (Be) High Blood Pressure (Be) Yes No

What medications are you taking for that?

What medications are you taking for that? (Beneficiary)

Stroke Stroke Yes No

Stroke (Be) Stroke (Be) Yes No

Was that a minor TIA or major stroke?

Was that a minor TIA or major stroke? (Beneficiary)

And when was that?

And when was that? (Beneficiary)

What medications are you taking for that?

What medications are you taking for that? (Beneficiary)

Cancer Cancer Yes No

Cancer (Be) Cancer (Be) Yes No

And when were you diagnosed?

And when were you diagnosed? (Beneficiary)

When was your last treatment?

When was your last treatment? (Beneficiary)

Asthma Asthma Yes No

Asthma (Be) Asthma (Be) Yes No

Is that seasonal, moderate, or severe?

Is that seasonal, moderate, or severe? (Beneficiary)

What medications are you taking for that?

What medications are you taking for that? (Beneficiary)

Have you ever been hospitalized for asthma? Have you ever been hospitalized for asthma? Yes No

Have you ever been hospitalized for asthma? (Be) Have you ever been hospitalized for asthma? (Be) Yes No

Arthritis Arthritis Yes No

Arthritis (Be) Arthritis (Be) Yes No

And how long have you had Arthritis?

And how long have you had Arthritis? (Beneficiary)

Is that Rheumatoid Arthritis or Osteo? Is that Rheumatoid Arthritis or Osteo? Rheumatoid Osteo

Is that Rheumatoid Arthritis or Osteo? (Be) Is that Rheumatoid Arthritis or Osteo? (Be) Rheumatoid Osteo

Any medications for that?

Any medications for that? (Beneficiary)

COPD COPD Yes No

COPD (Be) COPD (Be) Yes No

Do you use oxygen? Do you use oxygen? Yes No

Do you use oxygen? (Be) Do you use oxygen? (Be) Yes No

Any other medications for that?

Any other medications for that? (Beneficiary)

Diabetes Diabetes Yes No

Diabetes (Be) Diabetes (Be) Yes No

Do you take any Insulin or stick to a special diet? Do you take any Insulin or stick to a special diet? Insulin Special Diet

Do you take any Insulin or stick to a special diet? (Be) Do you take any Insulin or stick to a special diet? (Be) Insulin Special Diet

Any other medications for that?

Any other medications for that? (Beneficiary)

Major Surgeries

Major Surgeries (Beneficiary)

When was that?

When was that? (Beneficiary)

Any pain medications for that?

Any pain medications for that? (Beneficiary)

Disabilities

Disabilities (Beneficiary)

Age of disability

Age of disability (Beneficiary)

Felonies, Misdemeanors, DUIs Felonies, Misdemeanors, DUIs Felonies Misdemeanors DUIs

Felonies, Misdemeanors, DUIs (Be) Felonies, Misdemeanors, DUIs (Be) Felonies Misdemeanors DUIs

Employment Info

What do you do for work?

Employment (Beneficiary)

What's your work schedule like?

Employment Hours (Beneficiary)

What's your annual income?

Yearly Income (Beneficiary)

Do you have any existing coverage in place? Do you have any existing coverage in place? Work Life Mortgage

Do you have any existing coverage in place? (Be) Do you have any existing coverage in place? (Be) Work Life Mortgage

How much coverage do you have through work?

How much coverage do you have through work? (Beneficiary)

How much is your life policy for?

How much is your life policy for? (Beneficiary)

How much is your mortgage policy for?

How much is your mortgage policy for? (Beneficiary)

What company is that with?

What company is that with?

How much is your monthly premium on your mortgage coverage?

How much is your monthly premium on your mortgage coverage? (Beneficiary)

Appointment

Day

Time

Date

Best email for contact?

Phone Number

Notes