COURTER FINANCIAL SERVICES, LLC

ID #

What type of Life Insurance are you looking for?

How much Term Insurance are you looking for?

How much Permanent Insurance are you looking for?

How much Final Expense Insurance are you looking for?

Do you have any existing Life Insurance policies?

Yes
No

If yes, please list the Type of policy, the Premiums you pay, and the Death Benefit of the policy.

Do you have money (Cash Value) in an existing life insurance policy?

Yes
No
Unsure

If yes, how much Cash Value is in your existing policy?

How would you prefer to pay for this policy?

Annual
Semi-Annual
Quarterly
Monthly (Bank Draft)

Are you willing to have a Para-Medical Exam? (blood/urine collection)

Yes
No

Have you had any parents/siblings that died prior to age 60?

Yes
No

If yes, please list the relationship of that family member. Also list the cause of death, age at diagnosis, & age at death.

Do you have any health issues?

Yes
No

If yes, please list any diagnosis, surgeries, hospitalizations, treatments, etc. Please include the date of the most recent treatment or incident as well as how long ago the condition was diagnosed.

Do you currently take any medications?

Yes
No

If yes, please list the name, dosage, & frequency of each medication.

Are you currently (or within the last 12 months) receiving counseling for mental health issues?

Yes
No

If yes, please explain:

What is your height?

What is your weight?

Has your weight changed in the last 12 months?

Yes
No

If yes, please list the number of pounds you have gained/lost as well as the reason for the change:

Would you like us to quote a Waiver of Premium Rider that would waive premiums if you become permanently disabled?

Yes
No

Would you like us to quote a Child Rider that would provide guaranteed insurability and death benefit for your kids?

Yes
No

Would you like a quote for Cancer/Critical Illness coverage to pay for expenses not covered by your health insurance?

Yes
No

Are you a U.S. Citizen?

Yes
Yes - Naturalized Citizen
No - Permanent Resident
No

If No, what country were you born in?

What is your Annual Household Income?

What is your Net Worth (Total Assets, minus Total Debt)?

Please include any other information you feel is important for us to consider so that we can provide the most accurate quotes possible (please do not include Personally Identifiable Information):

COURTER FINANCIAL SERVICES, LLC

Since 1972