COURTER FINANCIAL SERVICES, LLC

ID Code

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?

What is your Total Household Income?

What is your Total Household Net Worth?

Do you have any existing Life Insurance policies?

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

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

How would you prefer to pay for this policy?

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

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

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 problems?

If yes, please list any diagnosis, surgeries, hospitalizations, treatments, etc. Please include how long ago the condition was diagnosed.

Do you currently take any medications?

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?

If yes, please explain:

What is your height?

What is your weight?

Has your weight changed in the last 12 months?

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?

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

If you have any existing life insurance policies, please list the Type of policy, premiums you pay, and the death benefit of the policy.

Please include any other information you feel is important for us to consider so that we can provide the most accurate quotes possible:

Since 1972