LIFE INSURANCE POLICY FORM
Requirements for Life Insurance
Please fill out the following form to complete the Life Policy application.
APPLICANT'S DETAILS
Full name and surname
Gender
Female
Male
Age
Are you a EE.UU citizen?
Yes
No
Do you have Permanent Residency or Work Permit? (If you are a EE.UU Citizen, do not answer)
Yes
No
Social security number (if applicable)
Date of birth (MM/DD/YYYYYY)
Years in the United States
Place of birth
E-mail
Cell phone number
Complete home address
Name of the company where you work
Occupation
Time at work
Personal income
MEDICAL HISTORY
Do you have any existing medical conditions?
Yes
No
If yes, your answer is to indicate which of these diseases exist
Do you take any medication?
Yes
No
If yes, please indicate which medication(s) you are taking and indicate the milligrams of each medication
Are you a smoker?
Yes
No
What is your weight?
How tall is it?
FAMILY HISTORY
Is your father alive?
Yes
No
If not, what did he die of?
Age when his father died
Is your mother alive?
Yes
No
If not, what did he die of?
Age at mother's death
Mother's date of birth (MM/DD/YYYYYY)
Father's date of birth (MM/DD/YYYYYY)
CRIMINAL RECORDS AND TRAFFIC VIOLATIONS
Do you have a criminal record?
Yes
No
Do you have Traffic Tickets?
Yes
No
BENEFICIARY DATA #1
Beneficiary Name
Beneficiary's date of birth (MM/DD/YYYYYY)
Beneficiary's Social Security Number (if applicable)
Relationship
Spouse
Child
Cohabitant
Friend
Cousin
Grandparent
Aunt/Uncle
BENEFICIARY #2 DATA (IF APPLICABLE)
Beneficiary Name
Beneficiary's date of birth (MM/DD/YYYYYY)
Beneficiary's Social Security Number (if applicable)
Relationship
Spouse
Child
Cohabitant
Friend
Cousin
Grandparent
Aunt/Uncle
BENEFICIARY DATA #3 (IF APPLICABLE)
Beneficiary Name
Beneficiary's date of birth (MM/DD/YYYYYY)
Beneficiary's Social Security Number (if applicable)
Relationship
Spouse
Child
Cohabitant
Friend
Cousin
Grandparent
Aunt/Uncle
BENEFICIARY DATA #4 (IF APPLICABLE)
Beneficiary Name
Beneficiary's date of birth (MM/DD/YYYYYY)
Beneficiary's Social Security Number (if applicable)
Relationship
Spouse
Child
Cohabitant
Friend
Cousin
Grandparent
Aunt/Uncle
CURRENT TREATING PHYSICIAN'S INFORMATION
Name of current treating physician (primary care physician) or treating physician in any area of your care
Address of this physician
Physician Phone Number
Date of last visit
Reason for visit
BANK DETAILS
Name of Bank Account Holder
Bank Name
Route number
Account number
Preferred date of payment of the 1st initial premium (MM/DD/YYYYY)
Preferred date for recurring payments
1st of each month
Every 15th of each month
Every 25th of each month
Every last of every month
Attach passport photo
Attach photo of Residency or Work Permit
Attach photo of Driver's License (if applicable)
Send form
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José Durán Insurance
Asesor de Seguros & Finanzas