Life Planning and Inventory

Services

Please be prepared to provide the following information so we may better advise you. You 
are welcome to open the attached word document and print for your records:

Information Page

Type of Policy : Term Life            Whole Life                 Universal Life

Amount :   100,000        250,000        500,000        1,000,000   

Over 1,000,000  contact TBA (we need to talk)

Sex                   M           F

Height               Feet        Inches

Weight              lbs.

Smoke              Yes         No

MEDICAL HISTORY

A) Illnesses

1) Type(s)

2) Date(s) of Diagnosis

3) Treatment


4) Medications

5) Last Visit to Doctor About Illness
0-6 months           6-12 months          12-24 months  
over 24 months

6) Date and Result of Last Cholesterol reading
a) date ________             reading ________

7) Date and Result of Last Blood Pressure Reading
a) date __________                   reading __________

8) Exercise sessions per week
1         2         3         4         5         6         7

B)  Other Medications
a) type _______________     b) dosage ___________  

D) Have you had a parent or sibling die before 65?          Yes         No

1) relationship(s) ____________________________

2) cause (s)  __________________________________

*Note: Mr. Bell is licensed in Kansas, Missouri, Pennsylvania, and 
Michigan.. Other States may be added if need. Please call or email for further 
information.

© 2015 by Robert E. Bell