Insurance Life Intake Form

INSURANCE LIFE INTAKE FORM

Applicant / Insured Information

Client Name:

Policy Details Requested

Requested Policy Type: Term Whole Universal

Coverage Options and Riders

Optional Riders (check all requested): Accidental Death Benefit Waiver of Premium (disability) Accelerated Benefit for Chronic/Terminal Illness Child Term Rider

Medical and Health History

Primary Care Physician: Phone:

Lifestyle and Activities

Tobacco / Nicotine Use (past 12 months): Yes No

Hazardous Activities (aviation, scuba, racing, military service, etc.):

Beneficiary Designation

Primary Beneficiary 1 - Name:

Primary Beneficiary 2 - Name:

Total allocation of primary beneficiaries must equal 100%. If percentages do not equal 100%, insurer will consider allocations to be equal shares unless otherwise specified.

Authorizations, Declarations and Notices

I certify that the information provided in this Intake Form is true, complete and correct to the best of my knowledge. I understand that any material misrepresentation or omission may result in denial of coverage or rescission of any issued policy. I acknowledge that this Intake Form is an application record and will be used by the insurer and its authorized representatives to evaluate eligibility and premiums.

Authorization to Obtain Records: I authorize any physician, medical practitioner, hospital, clinic, insurer, employer, or other relevant entity to release my medical records, employment records, and any other information reasonably requested by the insurer for purposes of underwriting and claims investigation. I understand that a copy of this authorization is as valid as the original.

Use and Disclosure: I consent to the insurer's use and disclosure of my health information and application data to affiliates, reinsurers, and authorized agents as necessary for underwriting, administration, rating, and claims handling. The insurer may also obtain consumer reports and other investigative information as permitted by law.

Incontestability and Effective Date: No statement made by the applicant in this Intake Form shall void coverage or be used to deny a claim unless contained in a written application provided to and relied upon by the insurer. Coverage, if issued, will not become effective until the policy is delivered and any required first premium is paid, and only if all representations remain true at that time.

Exclusions and Limitations: Coverage may be limited or excluded for suicide within the initial contestable period, participation in illegal acts, and losses resulting from declared or undeclared war or intentional self-harm. Specific exclusions will be set forth in the policy contract.

Acknowledgement

By signing below I acknowledge receipt of this Intake Form and consent to the authorizations and declarations contained herein. I understand that this Intake Form is an underwriting document and does not constitute a promise of coverage.

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