LIFE INSURANCE FORM

Virtual Life Insurance Form

This form is intended for clients to provide information for entry into our insurance agency’s online system.

Client Information

First Name *

Last Name *

Birthday *

Select your date of birth

Email *

[email protected]

Phone *

2143658709

Social Security Number *

Enter your last 4-digits only

Marital Status *

Employment & Income Information

Employment Status *

If you are employed, please answer the following questions:

Employer Name

Job Title

Annual Income Range

Length of Employment

Insurance Information

If you choose “Other,” please specify.

Current Insurance Provider (if any)
Policy Number (if applicable)
Coverage Start Date
Coverage End Date

Beneficiary Information (if applicable)

Beneficiary Full Name

Relationship

Beneficiary Date of Birth

Percentage Allocation

Medical Information (for applicable policies)

Do you have any pre-existing conditions?

If yes, please describe:

Are you currently taking prescribed medications?

Tobacco / Nicotine Use:

Additional Information

Have you had any claims in the past 5 years? *

If yes, please provide details:

Additional notes or requests: *

Consent & Authorization

By typing your name, this will serve as your electronic signature. By signing, you confirm that all information entered on this form is true and correct. By completing this form, you consent to Cliff Jones Financial Strategies using the information submitted to prepare your insurance and, where applicable, to apply for banking products on your behalf.

E-Signature *

Type your Full Name

Date of Submission *

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