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Life Insurance Form
Please complete the form below. All fields are required.
 
General Information
Name: *
Address: *
City:
* State: * Zip: *
Day Phone:
* Night Phone:
Best Time To Call:
AM PM
How Did You Hear About Us?:
E-mail Address: *
 
Current Life Insurance Information
Do You Currently Have Life Insurance:
  Y N
Company Name (not agency):
Monthly Premium: $
Is the Current Policy Term or Cash
Value Life Insurance:
Term Cash Value
What is Your Current Coverage
Amount: 		$
Why Are You Looking For A New Plan?:
 
Information About Yourself And Family
Please enter information below for all to be covered.
  Self Spouse Child #1 Child #2 Child #3
Name: Self
Date of Birth:
Sex:
  M F
  M F
  M F
  M F
  M F
Marital Status:
  M F
  M F
  M F
  M F
  M F
Occupation:
Height:
  ft. in.
  ft. in.
  ft. in.
  ft. in.
  ft. in.
Weight: lbs. lbs. lbs. lbs. lbs.
Have you/tdey
had any of the
following
health conditions:
Heart
Cancer
Diabetes
HBP
Heart
Cancer
Diabetes
HBP
Heart
Cancer
Diabetes
HBP
Heart
Cancer
Diabetes
HBP
Heart
Cancer
Diabetes
HBP

Used Tobacco
in past 24 months:

  Y N
  Y N
  Y N
  Y N
  Y N
 
Health History
Please list any individual Health history on each person to be covered
Is ANY person to be insured currently on prescription medications?
  Yes No
If yes, please list below.
Please describe ALL health conditions which may affect your application for Insurance:
 
Life Insurance Needs Calculator
To protect your financial privacy please write down the answers to the following
needs formula and enter a total amount for both yourself and your spouse after
you have determined your final Life insurance need.
 

(1) Multiply your Annual Income by 3
(Example: if your income is $50,000 the total will be $150,000)

$
(2) Add the amount you owe on your home plus miscellaneous debt
(Example if you owe $250,000 you will add this to $150,000 [above].
The total will be $400,000) 		$
(3) Add $50,000 for each dependent child in your household
(Example: if you have two children you will add $100,000 to $400,000.
Your total need will be $500,000) 		$
TOTAL LIFE INSURANCE NEED: (Self) $
TOTAL LIFE INSURANCE NEED: (Spouse) $
 
Life Insurance Options
  Self Spouse Child #1 Child #2 Child #3
Amount of
Coverage: 		$ $ $ $ $
Type of
Coverage:
Term
Permanent*
Term
Permanent*
Term
Permanent*
Term
Permanent*
Term
Permanent*
College
Savings: 		N/A N/A
  Y N
  Y N
  Y N
Retirement
Plan:
  Y N
  Y N
N/A N/A N/A
*Permanent Insurance Includes Universal Life, Variable Life, and Whole Life
 
Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have
additonal information where there was not enough fields above, such as additional drivers,
vehicles, driver histories, etc., please enter them here.
 

CHECK HERE: I acknowledge that the information I am providing in this submission
is true and accurate to the best of my knowledge.

 
You MUST check the box above in order to Submit this application.
 
 
  © 2004 Herzog Insurance Agency. All rights reserved.