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Life Insurance Application
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Applicant Information
Full Legal Name
*
First
Last
Date of Birth
*
Gender
Male
Female
Other
Phone
*
Email
*
City, State (Illinois only)
*
Preferred Method of Contact
Call
Text
Email
Coverage Details
Type of Life Insurance Requested:
Term Life
Whole Life
Universal Life
Final Expense
Not Sure (Need Guidance)
Desired Coverage Amount ($)
Coverage Purpose:
Family Protection
Mortgage Protection
Income Replacement
Business Protection
SBA Loan Requirement
Final Expenses
Desired Policy Length (Term only):
10 Years
15 Years
20 Years
30 Years
Health Information
Height
Weight
Tobacco / Nicotine Use in last 5 years?
Yes
No
Any of the following conditions?
High Blood Pressure
Diabetes
Heart Disease
Cancer
Stroke
Asthma
Anxiety / Depression
None
Any hospitalizations or surgeries in the last 5 years?
Yes
No
Currently taking prescription medications?
Yes
No
List medications & conditions
Lifestyle & Risk Information
Occupation
Any hazardous hobbies? (Aviation, scuba diving, racing, etc.)
Yes
No
DUI / DWI in the last 5 years?
Yes
No
Felony convictions?
Yes
No
Beneficiary Information
Primary Beneficiary Name
*
Relationship
*
Percentage (%)
*
Contingent Beneficiary
Existing Coverage
Do you currently have life insurance?
Yes
No
Carrier Name
Coverage Amount
Policy Type
Budget Preferences
etc.) Risk
Monthly Budget Range:
Under $50
$50–$100
$100–$200
Flexible
Anything else we should know to better assist you?
Consent
I certify that the information provided is accurate to the best of my knowledge
Authorization
I authorize Merrill Insurance Agency, Inc. to contact me and share my information with insurance carriers for quoting purposes
Submit
