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.
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
Smoke Yes No
2) Date(s) of diagnosis
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 firstname.lastname@example.org.
If you have questions, please contact Robert at 913-962-4392 or email@example.com.