Client Policy Setup Sheet

Client Policy Setup Sheet

Please fill out this form as thoroughly as possible to reduce processing time. Your information is encrypted and protected by our HIPAA compliant software. If you have any questions, please don't hesitate to reach out to your agent.

Team Ladder Strategists

with The Miliare Group

First and Last Name or Business Name*

My Agent is...*

Select or enter value

I am a....*

Select

Phone Number*

Email*

Date of Birth*

Male or Female?*

Select

Home Address*

Please include city/state/zip code

Length of Time at Address*

State of Birth*

Country of Birth*

Driver's License Number*

DL Expiration Date*

DL Issue State*

Social Security Number*

Height, Weight*

Marital Status*

Select

Number of Dependents*

Dependent's Names & Relationships*

Are you a member of any Armed Forces?*

Select or enter value

Employment Status*

Select

Employer Name*

Job Title*

Employer Address*

Employer Phone*

Length at Employer*

Salary/Income*

Net Worth*

If Trust, what is TIN?

Primary Beneficiary First Name*

Primary Beneficiary Last Name*

Relationship*

Primary Beneficiary DOB*

Primary Beneficiary SSN*

Primary Beneficiary Phone Number*

Primary Beneficiary Address*

Secondary Beneficiary First Name

Secondary Beneficiary Last Name

Relationship to Secondary

Secondary Beneficiary DOB?

Secondary Beneficiary SSN?

Secondary Beneficiary Phone Number

Secondary Beneficiary Address

Bank Name*

Bank Routing Number*

Bank Account Number*

Checking or Savings?*

Select

Final Objective

Select

Primary Care Physician Name*

Date of last visit*

Reason for last visit to Physician*

Diagnosed with any chronic conditions? Name these.*

Condition onset date*

Date of first diagnosis*

Date last seen by physician for condition*

D you take any prescriptions or medication?*

Name/dosage/frequency/and reason or current meds.

Have you ever had surgery, a CAT scan, or Xray?*

If so, give reason for diagnostic testing.

If pregnant, what is your due date?

In the last 5 years, used tobacco or marijuana?*

Type of tobacco/marijuana & date last used:*

Do you have any pets?

Do you have existing life insurance?*

Select

If so, what is Face Amount, Company, & Policy #?*

How many siblings do you have? Living or Deceased?*

Sex & Age of siblings?*

Age of mother & father? Living or Deceased?*

If deceased, what did they pass away from?

Medical concerns over last 10 years? Explain if so*

Traveled or will travel outside the US this year?*

Driving violations in the last 5 years?*

Any convictions in the last 10 years?*

For child account: Names, DOB's, and SSN's

For Child account: Height & Weight today/1 yr ago

For Child account: Any chronic conditions?

Additional Information

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