High Point Life Insurance Questionnaire

First Name *

Last Name *

Mobile Phone *

Email *

Address *

City *

State *

Postal code *

By providing my phone number, I agree to receive text messages from Highcrest Insurance Group.

Date of Birth *

City & State of Birth? *

Drivers License Number *

Drivers License State *

Drivers License Expiration *

Social Security Number *

Do you have any existing life insurance or annuity policies? *

Yes

No

Height (Feet & Inches) *

Weight (lbs) *

Tabacco Use? *

Gender *

Occupation? *

Employer Name? *

Date of Employment *

Appx Annual Income? *

$

Appx Net Worth? *

$

Any Current or Recent Medical Concerns That Would Come Up On Your Medical Records? *

Currently Taking Any Medications? If So, Include Medication Name, Dosage, Date Prescribed, and What It's for. *

Ever Had Any Heart, Neuro, Psychiatric, Nervous, or Other Health Concerns in the Last 10 Years? If Yes, Please Explain Each & Include Date of Diagnoses and Whether It's Ongoing. *

Any Blood Disorders Such as Diabetes, HIV, Sickle Cell, Etc? If Yes, Please Explain. *

Any Concerns You Have Not Sought Medical Attention for Yet? If Yes, Please Explain. *

Physician Name? *

Physician Contact Info? *

Date Last Seen By Physician? *

Reason for Visit? *

Any DUI/DWI or Felonies? If Yes, Please Explain. *

Engaged In Extreme Sport, Competition, Piloting? If Yes, Please Explain. *

Mother Living? *

Yes

No

Mother's Age? *

Deceased Mother Info

Age at death? *

Cause of death? *

Father Living? *

Yes

No

Father's Age? *

Deceased Father Info

Age at death? *

Cause of death? *

Number of living siblings? *

Age for each living sibling *

Number of deceased siblings? *

Deceased Siblings - Age at and cause of death *

Beneficiary Info

Full Name *

Percentage *

Date of Birth *

Social Security Number *

Add another beneficiary? *

Yes

No

Beneficiary #2

Full Name *

Percentage *

Date of Birth *

Social Security Number *

Add another beneficiary? *

Yes

No

Beneficiary #3

Full Name *

Percentage *

Date of Birth *

Social Security Number *

Add another beneficiary? *

Yes

No

Beneficiary #4

Full Name *

Percentage *

Date of Birth *

Social Security Number *

Please upload a picture of a voided check for the bank account you would like your monthly payment/contribution drafted from. *

Click here to upload

Photo of Driver's License *

Driver's License

Recent medical records, paramedical or exam results.

Any Docs to Attach?

Please let us know if you have any other information or questions to share.

Additional Notes

ATTESTATION

THIS IS NOT AN OFFICIAL LIFE INSURANCE APPLICATION. THIS DOCUMENT IS A SHORT FORM USED TO AID IN THE APPLICATION PROCESS. ANSWERS ON THIS FORM WILL BE USED TO FILL IN AN OFFICIAL APPLICATION ON THE APPLICANTS BEHALF. BY SIGNING BELOW THE APPLICANT AGREES TO THIS USAGE AS WELL AS HEREBY CERTIFIES THAT ALL ANSWERS PROVIDED ARE TRUE AND ACCURATE TO THE BEST KNOWLEDGE OF THAT SAME APPLICANT. APPLICANT IS ALSO AWARE THAT ADDITIONAL INFORMATION MAY BE REQUESTED.

Signature *

Clear

Today's Date *

Life Insurance

Questionnaire

Please complete the life insurance questionnaire in it's entirety. If you have any questions, you can contact us at admin@highcrestins.com