Client Worksheet

Complete the Client Worksheet below to Qualify!

✔️ No Medical Exam

✔️ No Blood Test

✔️ Affordable Rates

✔️ Benefit Never Decrease

✔️Premium Never Increase

Client Information

All agents with Life Insurance Tools are REQUIRED to show proof of an active license before conducting ANY business. Any and all information will not be shared with another vendor or agency. The information will be used to match you with the carrier that meet your needs.

Call (877)585-4094 for assistance.

Enter Initials followed by 8 digit D.O.B.

Purposed Insured Name*

Purposed Insured Street Address*

City*

State*

Zip*

Phone Number*

Email Address*

SSN/ITIN #

Marital Status*

U.S. Citizen*

If no, specify country of citizenship

No.of Years

Type of Visa:

Driver’s License #*

Issue State*

Expiration Date *

Date of Birth*

City of Birth*

State of Birth*

Tobacco/Marijuana use?*

Sex*

Weight (lbs)*

Height (ft)*

(in)*

Product Type*

Remaining Auto Balance?

Remaining Mortgage Balance?

What’s an Affordable Monthly Premium?

Coverage Amount?

(1) Beneficiary Full Name

Relation to Beneficiary

Beneficiary Phone

Date of Birth

Percentage

(2) Beneficiary Full Name

Relation to Beneficiary

Beneficiary Phone

Date of Birth

Percentage

(1) Beneficiary Full Name

Relation to Beneficiary

Beneficiary Phone

Date of Birth

Percentage

(2) Beneficiary Full Name

Relation to Beneficiary

Beneficiary Phone

Date of Birth

Percentage

Are you, or have you been in close contact with anyone who has been quarantined or who has been diagnosed with COVID-19 (Coronavirus).*

Are you awaiting the result of a test which has already been submitted for the COVID-19 (Coronavirus)?*

Are you currently in good health?*

Have you traveled outside the USA (in the last 30 days)?*

If (YES), please provide details of your travel.Country, City, Date arrived, & Date departed

Do you intend to travel out of the USA within the next 30 days?*

Reside in an assisted living facility or retirement living facility?*

Reside in a nursing home or skilled nursing facility or psychiatric facility?*

Receive or have you been advised to receive skilled nursing care, hospice care, or home healthcare due to a terminal condition that is expected to result in death within the next 12 months or for a chronic condition or for a chronic illness?*

Require the use of a wheelchair due to a chronic illness, chronic condition or disease?*

Require assistance with any of the following activities of daily living: taking medications, bathing, dressing, eating, or toileting?*

View Privacy PolicyI confirm that the answers I have given are, to the best of my knowledge, true and that I have not withheld any material information that may influence the assessment or acceptance of this application. I agree that this form will constitute part of my application for insurance(s) and that failure to disclose any material fact by me may invalidate my insurance(s).*

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Life Insurance Tools, Helping You Protect Yourself, Your Loved Ones, and Most Importantly Those You Love.
206 New Edition Court Cary, NC 27511 and its subsidiaries. 021760 NC 12/21