Moseleymcgill – Financial Supplement for Personal Insurance

Financial Supplement for Personal Insurance Questionnaire
Please answer all questions applicable to the client's medical history.
Questions? Call Jim or Teresa at 877.564.1707.
Producer Name*
Phone*
Email*
Date
Date Format: MM slash DD slash YYYY
Client Name
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
- Male
- Female
Owner:
Beneficiary:
Purpose of Insurance
Assets
Cash (checking, savings, CDs):
Accounts, loans, and notes receivable:
U.S. Government and marketable securities:
Real estate (market value):
Personal Property (auto, furniture, etc.):
Other assets (describe below):
TOTAL ASSETS:
Liabilities
Accounts and notes payable:
Real estate mortgages or liens:
Other liabilities (describe below):
TOTAL LIABILITIES:
NET WORTH:
Description of other assets:
Description of other liabilities:
Last completed tax year:
Prior tax year:
Annual Salary:
Last Completed Tax Year Prior Tax Year
Bonus and commissions:
Last Completed Tax Year Prior Tax Year
Dividends and interest:
Last Completed Tax Year Prior Tax Year
Pension/annuity:
Last Completed Tax Year Prior Tax Year
Real estate income:
Last Completed Tax Year Prior Tax Year
Other income (describe below):
Last Completed Tax Year Prior Tax Year
Description of other income including source:
For Insurance Professional Use Only — not intended for use in solicitation of sales to the public. Products and programs offered through Tellus are not approved for use in all states. 07.06.17. Copyright © 2017 Tellus Brokerage Connections

Last Completed Tax Year	Prior Tax Year

Last Completed Tax Year	Prior Tax Year

Last Completed Tax Year	Prior Tax Year

Last Completed Tax Year	Prior Tax Year

Financial Supplement for Personal Insurance