Life Insurance Client Intake

McDonald Wealth Management · Licensed in Alabama & Tennessee

Your information stays on our own secure server

Got it — thank you.

I'll review your information and shop it across my carriers before we talk, so we can spend the call on real numbers instead of paperwork.

Next step: book your 30-minute consultation.

Book my consultation →

Please answer as completely as you can. The health questions determine which carriers can approve you — the more accurate this is, the better the options I can bring to our call.

About you

First name *

Last name *

Email *

Phone *

Date of birth *

Age *

Gender *

Last 4 of SSN *

Street address *

City, State, ZIP *

State born

Driver license number & state (optional)

Mother's maiden name (optional)

Primary care physician — name & office (optional)

Coverage & income Type of income *

Preferred draft frequency *

Preferred draft day of month

Do you have an existing life insurance policy? *

Yes No

Banking details are collected securely during the application itself — never on this form.

Beneficiaries

Primary beneficiary — full name *

Relationship *

Primary beneficiary — date of birth

Second primary beneficiary (optional)

Relationship

Contingent beneficiary (optional)

Relationship

Second contingent (optional)

Relationship

Health — the essentials

These questions decide which carriers can approve you. Answering honestly means I bring you real options instead of a decline. Nothing here disqualifies you from talking to me.

Height *

Weight (lbs) *

Do you currently use tobacco — cigarettes, cigars, chew, vape? *

Yes No

Have you used tobacco in the last 12 months? *

Yes No

Hospitalizations & surgeries Any surgeries or hospitalizations in the last 12 months? *

Yes No

Are you currently awaiting any surgery or procedure? *

Yes No

Diabetes Have you been diagnosed with diabetes? *

Yes No

Heart & cardiovascular Have you ever had a heart attack? *

Yes No

Diagnosed with heart disease? *

Yes No

Have you had heart surgery?

Yes No

Pacemaker?

If yes, date installed

Defibrillator / ICD?

If yes, date installed

AFib or irregular rhythm?

If yes, last occurrence

Congestive heart failure?

If yes, last occurrence

Stroke Have you ever had a stroke or TIA? *

Yes No

Cancer Have you ever been diagnosed with cancer? *

Yes No

Lung & respiratory Diagnosed with COPD or any lung disease? *

Yes No

Do you use oxygen?

If yes, how often

Do you have sleep apnea? *

Yes No

Current inhalers & respiratory medications — list all

Other conditions Do you have any of the following? Select all that apply * Anything else not listed above

Medications Current medications — name, dosage, and what it's for * Medications from the past 3–5 years you're no longer taking

Last thing Anything else relevant to your health or coverage needs How did you hear about McDonald Wealth Management?

Your information is stored on McDonald Wealth Management's own secure server and is used only to identify suitable coverage. It is never sold or shared.
Sydnie McDonald · Licensed in Alabama & Tennessee