Separated Eligibility Form

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Full Name

Phone *

Email *

Date of birth

Marital Status

Single
Married
Divorced
Widowed
Separated
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Age

Height

Weight

Smoker

Yes

Gender

Male

Female

Medical Details:

Please note these are not automatic declines, but it helps us get you qualified for the best IUL for you.

Medical Conditions

Heart Attack

Stent

Inhaler

Tyhroid Issues

Dialysis

Bipolar

Dementia

Stroke

Cancer

Lupus

Steroids

Kidney Disease

Anxiety

High Cholesterol

Alzheimer's Disease

Pacemaker

Diabetes

COPD

Oxygen

Liver Disease

Depression

Parkinson's Disease

HIV/ AIDS

Units Insulin:

A1C:

Have you had any surgeries in the last 10 years? Please list them and when.

When was the last time you visited your doctor?

Have you had any transplants? Please list any of them and when.

Have you had any medications prescribed? Even if you didn’t take them please list the name and dosage.

Legal Background:

Please check all that apply.

Resident

Yes

Addiction

Alcohol

Drug

If not Citizen or Resident, Do you have an ITIN?

Yes

Any DUI in the past, if so when

Do you have a permit to work in the United States?

Yes

Place of Birth

Financials

What is your Employment Status

What is your Occupation

Please provide approximate monthly income after deductions

Do you have a mortgage?

Yes

What is the mortgage balance?

What is the approximate housing cost per month?

What type of life insurance do you currently have?

Do you have a death benefit coverage amount in mind?

What is the coverage amount?

Are there any other obligations you would like to make sure are covered in case of your absence?

Do you have anything else in place that acts like life insurance, such as

401k

BONDS

IRA

Mutual Funds

ROTH-IRA

STOCKS

Significant Savings

It is protected from market risk?

Yes

What is most important for your long term plan?

Protection

Cash Value

Who will be your beneficiary?

IUL Interest

Why are you looking for this plan?

Mortgage Protection
IUL
Final Expense
Debt Management
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What is the amount you plan to deposit in this IUL monthly?

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For more information, visit chicagos-insurance.com.

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