Impartial Insurance Advisor Life Insurance Questionnaire

Please provide the following information. All fields are required or please enter “NA” if a field is not applicable. If you prefer, you may download and complete the PDF form offline and mail it to us: Click IIA Check-Up Questionnaire PDF. The Check-Up Questionnaire thumbnail will open. Click on the thumbnail page to open the PDF and download it. Please contact us if you have questions or are unable to download the PDF form. Thank you.

Personal Information of Primary

Please Enter Your Full Name *

Email Address *

Phone Number *

Best Time to Call *

Date of Birth *

Please use: mm/dd/yyy format

Street Address *

City *

State *

Zip Code *

Name of employer; how long you’ve been there; the nature of your job, its stability, do you like it, can you maintain it indefinitely and at the current income level? *

Information on Spouse

Full Name of Spouse

Spouse's Date of Birth

Please use: mm/dd/yyy format

Date of Marriage

Please use: mm/dd/yyy format

Name of her employer; how long she’s been there; nature her work, its stability, does she like it, can she maintain it indefinitely and at the current income level? If homemaker, does she have training that allows income capacity if needed (teacher, nurse, etc.)?

Children

Please enter the following information for each child: NAME, DATE OF BIRTH, and OCCUPATION/LOCATION

Other Information

Other dependents or plan additional children?

Any Special considerations? (blended family, dependent parents, health issues, etc.)

Do you have a trusted financial advisor? *

Yes

No

Who does your taxes (paid preparer, self, etc.)? * Self Prepared Paid Preparer

What are your top financial concerns? *