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Confidential · HIPAA-Compliant · No Obligation

Complete the intake questionnaire below at your own pace. Your responses are submitted securely and reviewed by a licensed advisor. This information is used solely for the purpose of evaluating coverage options on your behalf.

You will not receive a copy of this intake form. All information is handled in strict compliance with HIPAA federal privacy regulations. If you prefer to submit your information conversationally, .

Policy Role

Personal

Citizenship

Coverage

Lifestyle

Health

Medical

Riders

Before We Begin

One foundational question that determines how the application is structured.

Who is this policy for?

Will you be both the Owner and the Insured of this policy?

The Insured

The insured is the individual whose life is covered under the policy. The death benefit is payable upon the death of the insured. Their age, gender, and health classification determine the applicable premium rate.

The Owner

The owner is the party who holds and controls the policy - responsible for premium payments and entitled to designate or modify beneficiaries. The owner and the insured may be the same individual or separate parties (e.g., a spouse insuring a partner, or a parent insuring a child).

Most common scenario: The applicant is insuring their own life and will pay their own premiums. In that case, the owner and insured are the same individual - select Yes. If you are applying to insure another person's life, select No.

Section 1 - Personal Information

Basic identifying information for the individual to be insured.

First Name

Last Name

Date of Birth

Gender

Current Height

Current Weight (lbs)

Street Address

City

State

ZIP Code

Phone Number

Email Address

Section 2 - Citizenship & Residency

Citizenship and residency status affects eligibility across carriers and product types.

Current Citizenship / Residency Status

Length of U.S. Residency

Section 3 - Coverage Selection

Select the type of coverage you are seeking. If you are uncertain, visit our Insurance Education page for reference.

Primary Reason for Seeking Life Insurance Coverage

Policy Type

Term Life Insurance

Temporary coverage for a defined period. Pure death benefit protection - no cash value accumulation.

Preferred Term Length

Whole Life Insurance

Permanent lifetime coverage with cash value accumulation and guaranteed death benefit.

Preferred Structure

Desired Coverage Amount (Approximate)

Section 4 - Lifestyle & Background

These questions are used to identify the most appropriate carriers for your profile. All responses are confidential.

Current Employment Status

Gross Annual Income (if not a student)

Tobacco / Nicotine Use - Have you used nicotine in any form in the last 12 months?
(Includes: cigarettes, e-cigarettes, vapor products, pipe, snuff, chew, nicotine gum, patches)

High-Risk Activities - Do you participate in any of the following?
(Active-duty military aircraft pilots or crew, parachuting, scuba diving, handling explosives, or similar hazardous activities)

Driving Record - Have you had a DUI, reckless driving conviction, or license suspension or revocation in the past 5 years?

Criminal History - Do you have any felony convictions, pending criminal charges, or are you currently under legal supervision (probation or parole)?

Section 5 - Health Screening

Please answer each question as accurately as possible. All responses are reviewed by a licensed advisor and handled in full HIPAA compliance.

Have you been diagnosed with or treated for Alzheimer's disease, dementia, or significant memory loss?

Are you currently in hospice care, residing in a nursing home or skilled nursing facility, or receiving home healthcare services?

Have you had a heart attack or stroke within the last 6 to 12 months?

Have you had a suicide attempt within the last 2 to 5 years?

HIV / AIDS - Have you ever been diagnosed with or tested positive for HIV, AIDS, or ARC (AIDS-Related Complex)?

Respiratory Disease - Have you been diagnosed with COPD, emphysema, or chronic or severe asthma?

Liver or Kidney Disease - Have you been diagnosed with cirrhosis of the liver, active hepatitis, or chronic kidney disease (including dialysis)?

Heart Conditions - Have you been diagnosed with congestive heart failure, or had heart surgery including bypass or stent placement?

Neurological Conditions - Have you been diagnosed with a TIA (mini-stroke) or Multiple Sclerosis?

Active Cancer - Have you been diagnosed with or received treatment for any cancer within the last 12 months? (Excluding basal cell and squamous cell skin carcinomas)

Diabetes - Have you been diagnosed with Type 1 or Type 2 diabetes?

Mental Health - Have you been diagnosed with or received treatment for a mental health condition (including depression, bipolar disorder, schizophrenia, or anxiety disorders)?

Substance Use - Have you ever received treatment for alcohol or drug dependency or abuse?

Section 6 - Medical Details & Functional Status

Please list all current medications and indicate your level of independence with daily activities.

Current Medications
Please list all medications you are currently taking, including prescription and over-the-counter supplements. Start typing a name and select it from the suggestions, or type your own and click Add.

Known Health Conditions Not Previously Listed
Include any diagnosed conditions, surgeries, or hospitalizations in the past 5 years.

Activities of Daily Living (ADLs) - Independence Status
Select any ADLs for which you require assistance.

Instrumental Activities of Daily Living (IADLs) - Independence Status
Select any IADLs for which you require assistance.

Section 7 - Optional Riders

Riders are optional provisions added to a base policy that expand or modify coverage. Select any you would like to be considered. Rider availability, terms, and cost vary by carrier and are subject to underwriting guidelines.

Riders of Interest (Select all that apply)

Required Disclosures (Please read and confirm each before submitting)

FCRA - Fair Credit Reporting Act

As part of underwriting your application, the insurance company may order an investigative consumer report about you. This report can include things like your credit standing, character, general reputation, and lifestyle, and may draw on sources such as your prescription history, driving record, past medical billing, or lab results. If the company denies you coverage or charges you a higher rate because of something in this report, they must tell you and give you the name and address of the agency that prepared it, so you can request a copy, dispute anything inaccurate, and add your own statement.

MIB - Medical Information Bureau

Most insurance companies check the MIB before approving an application. The MIB is a shared database that member insurance companies use to flag information from your past applications or claims for life or health coverage. This helps companies catch fraud and keeps premiums fair for everyone by preventing people from hiding relevant health history. You have the right to request a copy of your MIB file directly from MIB if you would like to see what is on it.

State Privacy Practices Notice

Insurance companies are required in most states to give you a written explanation of how they collect and share your information. This means you have the right to see what information the company has on file about you, and the law limits who they are allowed to share it with, only well-defined parties directly involved in handling your policy, such as a company helping process your application.

HIPAA - Health Insurance Portability and Accountability Act

HIPAA is a federal law that protects the privacy of your health information. It means your medical history, conditions, and records cannot be shared without your written authorization, except in limited situations directly related to evaluating or servicing your application. Any health information you provide on this intake form is handled under these same protections.

Conditional Receipt

If you pay a premium at the time you submit a formal application, you will be given a Conditional Receipt. This document explains the specific terms under which you may have limited coverage while your application is still being reviewed and underwritten, and it is important that you read it carefully when it is provided.

I understand that information submitted on this form will be used by this licensed independent insurance advisory solely for advisor review and carrier eligibility evaluation. This form does not constitute an insurance application and does not guarantee coverage. I consent to being contacted by a licensed advisor regarding this inquiry.

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Intake Received.

Your intake responses have been submitted securely and will be reviewed by a licensed advisor. You will be contacted regarding your eligibility and available options. If you have questions in the interim, or visit the contact page.

Your Information Is Protected

HIPAA-compliant collection and handling
Not shared without explicit written authorization
Used solely for advisor review
You will not receive a copy of this form

What Happens After Submission

A licensed advisor will review your intake responses and evaluate your eligibility across our carrier network. You will be contacted with available options. No application is submitted without your explicit instruction.

MIB & FCRA Notice

Any formal application submitted to a carrier on your behalf may involve a Medical Information Bureau (MIB) inquiry and/or a consumer report under the Fair Credit Reporting Act (FCRA). You will be informed prior to any such inquiry being initiated.