CLIENT WORKSHEET

Complete the form below to find the best benefits and rates for your client. For two clients, fill out both forms; for one, complete just one.

PROPOSED INSURED #1

PROPOSED INSURED (SPOUSE)

PAGE #1

CLIENT INFORMATION

Full Name

Email *

Phone *

Date of Birth *

Gender

Height / Weight (lb)

HEALTH QUESTIONS 🚨

Have you ever been diagnosed with any of the following:

In the past 12 months have you used any form of tobacco?

Have you tested positive for HIV/AIDS or been diagnosed with a terminal illness? Are you bedridden, hospitalized, or need help with daily living like bathing, eating, or dressing?

Heart disease, attack, surgery, or failure? Stroke, aneurysm, seizures, lupus, or cancer? Lung disease, COPD, or oxygen use?

Any Liver, kidney issues, or dialysis? Diabetes with complications, neuropathy, or hepatitis b/c or organ transplants?

Any alcohol/drug abuse, DUI, felonies or parole? Depression, bipolar, schizophrenia, memory loss, Alzheimer’s, or dementia?

Are you retired or still working? *

List the Clients Health Conditions & Medications *

▪️ NOTE: Insert the clients diagnose dates and treatment dates

For your reference only —DO NOT discuss with the client. Use it to assess the rate class and continue with your script, entering all details into the insurance toolkits.

PREFERRED

BENEFIT OF PLAN:
If the client answered "no" to all health questions, has a healthy height and weight, minimal medications, and no major diagnoses in the past two years, they may qualify for the preferred rate class. This policy is for clients in excellent health, offering immediate coverage and the lowest premiums.

STANDARD

PROJECTED RATE CLASS

BENEFIT OF PLAN:

If the client has a stroke, lupus, seizures, COPD, hepatitis B/C, or abnormal height and weight, they may still qualify for a standard rate class. This policy is for moderate health clients, with immediate coverage and premiums $20-30 higher than preferred.

GUARANTEED ISSUE / MODIFIED

BENEFITS OF THE PLAN:

If the client answered "yes" in section one or to CHF, heart issues, cancer, oxygen use, sickle cell, or diabetic complications in the last two years, they likely qualify for GI or Modified plans. This policy has a two-year period where, if the client passes away, all premiums plus 10% interest are returned to beneficiaries. After two years, full coverage begins.

PAGE #2

PERMANENT COVERAGE that protects you your whole life.

Premiums NEVER increase. Benefits NEVER decrease.

You’re PROTECTED from THE FIRST DAY your policy is in effect.

Policy NEVER EXPIRES or cancels (as long as premiums are paid).

Coverage CAN NOT BE CANCELLED due to age or health changes.

BENEFITS PAY OUT within a 24-72 hours upon claim approval.

If the client doesn't qualify for preferred or standard (day one) coverage, ignore the third benefit mentioned above

Rate Class

Insurance Company

THREE OPTION WORKSHEET

Three Quotes (Options):

This section is for PHONE SALES agents only. Face-to-face agents, submit form and proceed directly to the application

BENEFICIARY SECTION

Primary Beneficiary(s) / %

Contingent Beneficiary(s) / %

PRE-QUALIFYING WORKSHEET

Home Address

Q: "What is the best address to mail the policy to?"

City

State

Postal code

PROPOSED INSURED SECTION

Drivers License / State ID

Q: They need to verify your identity, what is your drivers license #?

Primary Doctor / City & State

PLAN & PAYMENT INFO

Effective Draft Date

Q: Upon approval when do you want your policy to start?

Monthly Draft Date

Monthly Payment $

NOTES:

Begin the application process with your selected life insurance carrier. Keep the client on the phone as you submit!