Retirement Planning Store, Inc.
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Name
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First
Last
Address
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City
State
Zip Code
Country
Are you a U.S. Citizen?
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Yes
No
Phone Number
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Email
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Birth Place
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Marital Status
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Choose
Single
Married
Divorced
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Legally Seperated
Other
Nicotine Usage?
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Never
Quit
Currently Use
We use Email to correspond with our clients most of the time. Also, we do not sell your personal information. The information used on this form is for the purchase of life insurance only!
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Beneficiary Information
Primary:
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Primary:
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Contingent
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Contingent
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Please list an other beneficiaries / requests in this comment box.
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Percentage Split
Percentage
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Percentage
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Percentage
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Percentage
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Occupation
Occupation
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Number of Years at current occupation
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Annual Income
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Household Income
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Net Worth
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Employer Name
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Duties
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Work Address
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Address
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Line 1
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City
State
Zip Code
Country
Additional Questions
Have you consulted a physician for the use of Alcohol or drugs?
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Yes
No
Have you had any moving violations in the last 5 years?*
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Yes
No
If Yes, Please explain
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Drivers License Number
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In what State was your license issued?
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Have you had your drivers license revoked or suspended?
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Yes
No
If Yes, Please explain
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Submitted an application with any other company?
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Yes
No
If Yes, Who? and How much?
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Who is your personal Doctor?
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Approximate date of your last visit
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Reason for last visit
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Results
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Physician Address:
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Line 1
Line 2
City
State
Zip Code
Country
Physician Phone Number
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Do you have additional Physicians? Tell us about them here!
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Do you drink alcohol?
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Yes
No
If yes: # of drinks Daily
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Weekly?
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Other
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Are you a pilot or engage in hazardous activities, scuba diving, Mtn. climbing, racing, parachuting, hang gliding, etc.?
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Yes
No
If Yes, Please explain
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Had an application declined, postponed, or rated?
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Yes
No
If Yes, Please Explain
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Bankruptcy, tax lien or judgment filed against you?
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Yes
No
If Yes, Please explain
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Do you intend to travel outsite of the U.S. in the next 2 years?
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Yes
No
Existing Life Insurance
Do you have existing life insurance?
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Yes
No
If Yes, Company name?
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Death Benefit Amount?
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Type of Coverage
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Term
Whole Life
Universal Life
Variable Universal Life
Supplied at Work
Other
Do you plan on replacing this policy?
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Yes
No
If you have other life insurance policies please tell us about them here. If you plan on replacing, we need to know this.
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In the past 10 years, has the Proposed Insured:
A: Used barbiturates, hallucinatory drugs, narcotics, including crack, ecstasy, opium derivatives, marijuana, LSD, PCP, or any derivatives of these drugs, or been advised by a licensed medical professional to get medical treatment or undergone any medical treatment, counseling or hospitalization for drug abuse?
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Yes
No
C: Been advised by a licensed medical professional to limit your alcohol use or been advised to get medical treatment, or undergone any medical treatment or counseling or hospitalization for alcoholism, excessive alcohol use or abuse? Or, have you subsequently consumed alcohol after receiving counseling or medical treatment for alcohol use? Or, drink on average more than 3 alcoholic drinks per day?
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Yes
No
B: Pled guilty to or been convicted of a felony or misdemeanor? If yes, provide details on the nature of the plea or conviction, the date and state where the plea or conviction occurred, and whether time was served in prison.
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Yes
No
D: Been refused for life insurance or charged an extra premium for life insurance?
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Yes
No
E: Had your driver’s license revoked or suspended or been convicted of reckless driving, driving without a valid license, or for driving while under the influence of alcohol or drugs (DWI, DUI)? ..
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Yes
No
Has the Proposed Insured:
F: Within the past five years, had his/her driver’s license revoked or suspended or been convicted of reckless driving, driving without a valid license, or for driving while under the influence of alcohol and/or drugs (DWI, DUI)?
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Yes
No
H: Within the past five years, had more than one speeding violation or, motor vehicle moving violation, been involved in any accident in which he/she was found to be at fault, or pled guilty or been convicted for driving under the influence of alcohol?
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Yes
No
J: Traveled to or resided for more than 30 days outside of the U.S., U.S. territories, Canada, or Japan within the past 12 months or plan to travel to or reside outside of the U.S., U.S. territories, Canada, or Japan in the next 12 months?
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Yes
No
G: Flown a plane in the past 24 months or plan to fly in the next 12 months as a pilot, copilot, student pilot, military pilot, engineer or in any other capacity except as a regularly scheduled commercial airline pilot or fare-paying passenger?
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Yes
No
I: In the past 12 months or in the next 12 months, engaged in or plan to engage in the following recreational activities: hang gliding, skydiving, motor vehicle/cycle racing, rock climbing, ballooning, bungee jumping, mountain climbing, motor boat racing, snowmobile racing, ultra light aircraft flying, scuba diving to more than 50 feet in depth, or in caves, ship wrecks or deep seas?
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Yes
No
K: Had or have any bankruptcy pending or expect to file bankruptcy in the next 12 months?
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Yes
No
If Yes, to any of the above questions, Please provide details.
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In the past 10 years, has any person proposed for insurance been diagnosed by a licensed medical professional, treated or advised to get medical treatment from a licensed medical professional, hospitalized, or presently taking prescription(s) or medication(s) for any of the following disease(s) or disorder(s):
1. Angina, chest pain, heart attack, heart failure, heart surgery, irregular heartbeat, abnormal EKG, coronary artery bypass, angioplasty, stents, peripheral vascular disease, poor circulation, valvular heart disease, cardiomyopathy or heart murmur?
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Yes
No
2. High blood pressure, hypertension or abnormal cholesterol levels? .
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Yes
No
3. Stroke, seizures, epilepsy, dizziness, fainting, memory disorder or any other neurological or brain disorder?
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Yes
No
4.Multiple Sclerosis, neuritis, neuropathy, paralysis, muscular dystrophy, Parkinson’s disease or any other disorder of the muscles?
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Yes
No
5: Arthritis, chronic pain, fibromyalgia, connective tissue disease, lupus or scleroderma?
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Yes
No
6: Cancer, malignancy, tumor, melanoma, lymphoma, Hodgkin’s disease or leukemia?
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Yes
No
7: Chronic obstructive pulmonary or lung disease, chronic bronchitis, emphysema, sarcoidosis, asthma, shortness of breath, tuberculosis or sleep apnea?
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Yes
No
8: Diabetes, abnormal blood sugar, sugar in the urine, disease or disorders of the adrenal, parathyroid, pituitary or thyroid glands?
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Yes
No
9: Disorder of the kidney, bladder or urinary system, abnormal PSA, abnormal PAP smear without subsequent normal PAP smear or protein or blood in the urine?
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Yes
No
10: Anemia, hemophilia, clotting disorder or any other disorder of the blood?
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Yes
No
11: Immune Deficiency disorder (Acquired Immune Deficiency Syndrome (AIDS)), AIDS related complex (ARC) or been told test results indicate exposure to the AIDS virus?
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Yes
No
12: Colitis, ulcerative colitis, Crohn’s, esophageal varices, peptic or gastric ulcer, intestinal or rectal bleeding, diverticulitis, colon polyps, cirrhosis, hepatitis, liver failure, liver impairment, loss of bowel function or other disease or disorder of the liver or pancreas?
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Yes
No
13: Depression, anxiety, stress, eating disorder or any other nervous, mental or emotional condition? .
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Yes
No
Other than indicated above, has the Proposed Insured:
14: In the past 5 years, been diagnosed, treated or advised to get medical treatment from a licensed medical professional for any mental or physical disorder or medically or surgically treated condition not listed above?
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Yes
No
15: Had a parent or sibling who before age 60 was diagnosed with or died from cardiovascular disease, stroke, cancer (except basal or squamous cell cancer of the skin), Huntington’s Chorea, familial polyposis or polycystic kidney disease?
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Yes
No
16: Had a weight gain or loss of 10 or more pounds within the past 12 months for any reason other than pregnancy?
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Yes
No
17: Is the Proposed Insured currently receiving or have an application pending for any illness or disability benefits or compensation?
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Yes
No
18: Except for tests related to Human Immunodeficiency Virus (AIDS virus), in the past 12 months been advised by a licensed medical professional to have a check up, EKG, X-ray, blood or urine test or any other diagnostic test, or sought medical advice or treatment for any reason?
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Yes
No
19: In the past 12 months been advised by a licensed medical professional to be admitted to a hospital, medical facility, nursing home or assisted living facility?
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Yes
No
20: Is the Proposed Insured currently taking any prescription medications?
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Yes
No
21: If yes, list the medications and remedies and the reasons for which they are taken.
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Send!