Life Insurance Review

Life Insurance Information Form

Please complete the short form below so our team can better understand your current situation, coverage needs, and goals. This information will help us prepare for your review and make the conversation more productive.

Client Information

Fill out the form as completely as possible. If you are unsure about an answer, give your best estimate.

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Select Your Agent(Required)

Please select your agent from the list below

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Agent Name, First

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Agent Name, Last

Agent Your Life Insurance Agent is Roy Matlock

Your Full Legal Name(Required)

Date of Birth(Required)

Gender(Required)

Male

Female

Is the Insured a U.S. Citizen or legal permanent resident?(Required)

Yes

Social Security Number(Required)

Where was the insured born?(Required)

Insured's Birth State(Required)

Marital Status(Required)

Does Insured use tobacco products?(Required)

Yes

Insured's Height

Insured's Weight

Insured's Primary Physician Name

Insured's Primary Physician Contact Phone

Insured's Last Doctor Visit Date

Insureds Current List of Medications

Email(Required)

Enter Email Confirm Email

Current Residential Address(Required)

May NOT be a P.O. Box

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone(Required)

Alternate Phone

Driver's License Upload (Front of License)(Required)

Drop files here or

Max. file size: 32 MB, Max. files: 2.

Is the Insured currently Employed(Required)

Yes

Insured's Employer Information

Current Employer Name(Required)

Current Employer Phone(Required)

Employer's Address(Required)

Street Address City State ZIP Code

Number of years employed(Required)

Date employment began(Required)

Hours worked per week(Required)

Job Duties(Required)

Annual Salary(Required)

Household Net Worth(Required)

Applicant Owner Information

Will the Applicant be the Owner for this Policy?(Required)

Yes

Applicant Owner's Name(Required)

First Last

Email(Required)

Cell Phone(Required)

Applicant Owner's Address(Required)

Street Address City State ZIP Code

Applicant Owner's Date of Birth(Required)

Applicant Owner's SSN(Required)

Relationship to the Insured(Required)

Primary Beneficiary

Share equally among all primary beneficiaries

Relationship to Insured(Required)

Primary Beneficiary: Full Legal Name(Required)

First M.I. Last Suffix

Is 1st Beneficiary Address same as insured?(Required)

Yes

Primary Beneficiary Address

Street Address City State ZIP Code

Primary Beneficiary: Date of Birth(Required)

Social Security Number

Would you like to add an additional beneficiary?

Yes, I would like to add another beneficiary

Additional Beneficiary 1 relationship to Insured(Required)

Additional Beneficiary 1: Full Legal Name(Required)

First M.I. Last Suffix

Is beneficiary 2 address the same as insured?(Required)

Yes

Second Beneficiary Address

Street Address City State ZIP Code

Additional Beneficiary 1: Date of Birth(Required)

Additional Beneficiary 1: SSN

Would you like to add a third beneficiary?

Yes, I would like to add another beneficiary

Additional Beneficiary 2 relationship to Insured(Required)

Additional Beneficiary 2: Full Legal Name(Required)

First M.I. Last Suffix

Is third beneficiary address the same as insured?(Required)

Yes

Address

Street Address City State ZIP Code

Additional Beneficiary 2: Date of Birth(Required)

Additional Beneficiary 2: SSN(Required)

Coverage Information

Coverage Amount(Required)

Term Length(Required)

10 Years

15 Years

20 Years

30 Years

Riders and Benefits

Accidental Death Benefit

Waiver of Premium

Child Term Rider

Child 1 Name(Required)

Child 1's Date of Birth(Required)

Child 1's Height(Required)

Child 1's Weight(Required)

Would you like to add a second child rider?(Required)

Yes

Child 2 Name(Required)

Child 2's Date of Birth(Required)

Child 2's Height(Required)

Child 2's Weight(Required)

Would you like to add a third child rider?(Required)

Yes

Child 3 Name(Required)

Child 3's Date of Birth(Required)

Child 3's Height(Required)

Child 3's Weight(Required)

If you need to add additional children, please contact your advisor to get them added.

Payment Frequency(Required)

Monthly

Quarterly

Semi-Annually

Yearly

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Automatic Premium Bank Draft?

Yes, I can upload a voided check image

Yes, I can provide my routing and account number

No, I will pay another way

Upload Voided Check for Automatic Premium Draft

Max. file size: 20 MB.

Bank / Institution Name

Account Type

Bank Account Number

Bank Routing Number

Will the coverage applied for replace or change any existing life insurance or annuity contract with the company or any company?(Required)

Yes

Do you currently have life insurance or an annuity, not including insurance through an employer?(Required)

Yes

Company name for existing policy:(Required)

Existing policy number here:(Required)

Will you be cancelling or keeping this policy after new policy begins?(Required)

Cancelling

Keeping

How much life insurance do you currently have?(Required)

How long have you known the issuing agent?(Required)

And in what capacity?(Required)

Please tell us in what capacity you know the issuing agent

What is the source of funds used to pay premiums on this policy should it be issued?(Required)

About the Policy Owner

Full Legal Name

First Middle Last Suffix

Date of Birth

Social Security Number

Gender

Male

Female

Relationship to Insured

Current Residential Address

May NOT be a P.O. Box

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone

Alternate Phone

Contingent Beneficiary

Would you like to designate a contingent beneficiary?

Yes

Relationship to Insured

Contingent Beneficiary Full Legal Name

First M.I. Last Suffix

Birth Date

Social Security Number

Account Setup Information

This section is intended for an RMJ Representative to complete. If you are the client, you may submit this application without completing this section.

Notes