Client Questionnaire

US Citizen?
Do you have Life Insurance currently?

Personal History

Currently Disabled?
Tobacco Use over the past 2 years? Or CBD/Hemp Usage?
Have you been convicted for a DWI or DUI in the past 5 years?
Have you ever been convicted for a felony?
Have you been in a car accident where you were found at fault and CITED in the past 3 years?
Do you have any BOOKED foreign travel over the next 2 years?
Are you enlisted or intend on joining the Military?
Are you or do you plan on becoming a licensed pilot?
Do you participate in any extreme sports such as bungee jumping, rock climbing, racing cars, scuba diving, parachuting, or anything "extreme"?
Do you have a primary care physician?

Employer Information

Note: If retired, type N/A under the fields below that do not apply to you.

Finances + Savings

What are your financial concerns? (Please check all that apply)