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Life Planning and Inventory

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


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) How many time per week do you exercise
1         2         3         4         5         6         7

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

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

1) Relationship(s) ____________________________

2) Cause (s)  __________________________________

*Note:  Robert is licensed in Kansas, Missouri, Pennsylvania, Florida and Michigan.
Other states may be added if need.  Please return this completed form to

If you have questions, please contact Robert at 913-962-4392 or

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