Separated Eligibility Form

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Eligibility Form

Full Legal Name *

Phone *

Email *

Date of birth

Age

Weight

Height

Marital Status

Single
Married
Divorced
Widowed
Separated
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Gender

Male

Female

Smoker?

Yes

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

Stroke

Pacemaker

Stent

Cancer

Diabetes

Units Insulin:

Lupus

COPD

Inhaler

Steroids

Oxygen

Thyroid issues

Kidney Disease

Liver Disease

Dialysis

Anxiety

Depression

Bipolar

High Cholesterol

Parkinson's Disease

Dementia

Alzheimer'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 medications prescribed? Even if you didn’t take them please list the name and dosage.

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

Legal Background:

Please check all that apply.

Alcohol/Drug Addictions

Resident

Yes

Any DUI in the past, if so when

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

Yes

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?

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

What is the coverage amount?

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

401k

IRA

ROTH-IRA

STOCKS

BONDS

Mutual Funds

Significant Savings

It is protected from market risk?

Yes

Who will be your beneficiary?

IUL Interest

Why are you looking for this plan?

Option 1
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What is most important for your long term plan?

Protection

Cash Value

What is the amount you plan to deposit in this IUL monthly?

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