Questionnaire – Family Insurance Agency

548 Market St. Suite 712318, San Francisco, CA 94104
Support@familyinsagancy.com
+ 800-826-3167

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About Us
Services
- Life Insurance
Contact Us
Membership
- Phencom Members
- Questionnaire

QUESTIONNAIRE TO GENERATE
YOUR INSURANCE ILLUSTRATION

Please answer the following questions to the best of your ability. Your responses will help us identify the most suitable provider based on your medical history and other details

Personal Information

Full Name:

Date of Birth:

Gender

Female Male

Marital Status:

Number Of Dependents:

Phone Number:

Email:

Mailing Address:

Financial Information

Annual Income:

Estimated Net Worth:

Current Occupation:

Existing Life Insurance Policies:

Health Information

Do you use tobacco products?

No Yes

Do you have any chronic health conditions?

No Yes

Are you currently taking any medications?

No Yes

Policy Preferences

Desired Coverage Amount:

Preferred Premium Payment Frequency:

Quarterly Monthly Annually

Investment Preferences for cash Value:

Moderate Conservative Aggressive

Do you prefer a policy with flexible premiums and death benefits?

No Yes

Retirement and Estate Planning

Planned Retirement Age:

Do you Intend to use the policy's cash value to supplement retirement income

No Yes

Are you interested in estate planning benefits?

No Yes

Additional Information

How did you hear about us?

Any specific questions or concerns regarding IUL insurance?

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548 Market St. Suite 712318, San Francisco, CA 94104
800-826-3167
Support@familyinsagancy.com

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QUESTIONNAIRE TO GENERATE YOUR INSURANCE ILLUSTRATION

QUESTIONNAIRE TO GENERATE
YOUR INSURANCE ILLUSTRATION