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FAQ
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Mi Poliza

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PROPOSED INSURED INFORMATION

LIFE APP INFO SHEET

PROPOSED INSURED INFORMATION

Full name

Contact Number

Email Address

Address

Address

City

State

Zip code

How long at this address?

Social Security Number

Birth Date

Current Age

Gender

Male

Female

Driver’s License Number

Expiration Date

State Licensed

State of Birth

Are you a U.S. citizen?

Yes

No

If “No,” currently a citizen of what country?

If non-US citizen, do you have a U.S. Green Card?

Yes

No

Net Worth: $

Net Annual Income: $

All Other Income: $

PROPOSED INSURED EMPLOYMENT INFORMATION

Is the Insured retired or a full-time student?

Yes

No

Occupation/Position

Present Employer

Type of Business

Address

Address

City

State

Zip code

OWNER INFORMATION

Is the owner the proposed insured? Yes - No (If not, fill out owner information below)

Yes

No

Name of Owner or Trustee of Trust

Relationship to Insured

Birth Date

Full Name of Trust (If Applicable)

Date of Trust

Address

Address

City

State

Zip code

Social Security Number/Tax ID

Driver’s License Number/State

Expiration date

HEALTH INFORMATION

Height:

ft.

in.

Weight

Name of Personal Physician

Address of Physician

Date and Reason Last Consulted

BENEFICIARY INFORMATION

Primary Beneficiary or Name of Trustee

Relationship to Insured

Name of Trust (If Applicable)

Date of Trust

Contingent Beneficiary(ies)

Name

Name

Name

SSN

SSN

SSN

D.O.B

D.O.B

D.O.B

%

%

%

SPOUSE INFORMATION

Full name

Contact Number

Email Address

Social Security Number

Birth Date

Current Age

Gender

Male

Female

Driver’s License Number

Expiration Date

State Licensed

State of Birth

Are you a U.S. citizen?

Yes

No

If “No,” currently a citizen of what country?

If non-US citizen, do you have a U.S. Green Card?

Yes

No

Net Worth: $

Net Annual Income: $

All Other Income: $

SPOUSE EMPLOYMENT INFORMATION

Is the Insured retired or a full-time student?

Yes

No

Occupation/Position

Present Employer

Type of Business

Address

Address

City

State

Zip code

SPOUSE HEALTH INFORMATION

Height:

ft.

in.

Weight

Name of Personal Physician

Address of Physician

Date and Reason Last Consulted

CHILDREN INFORMATION

Full name

Social Security Number

Birth Date

Current Age

Gender

Male

Female

State of Birth

Are you a U.S. citizen?

Yes

No

If “No,” currently a citizen of what country?

Health information

Hgt

Wgt (lbs)

Full name

Social Security Number

Birth Date

Current Age

Gender

Male

Female

State of Birth

Are you a U.S. citizen?

Yes

No

If “No,” currently a citizen of what country?

Health information

Hgt

Wgt (lbs)

Full name

Social Security Number

Birth Date

Current Age

Gender

Male

Female

State of Birth

Are you a U.S. citizen?

Yes

No

If “No,” currently a citizen of what country?

Health information

Hgt

Wgt (lbs)

PEDIATRICIAN INFORMATION

Name of Pediatrician

Address of Pediatrician

Date and Reason Last Consulted

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Nombre

Email

Numero telefónico

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