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.