Foreign National QuestionnairePlease complete this form for any foreign national applicant (any insured residing inside the United States who is neither a US citizen nor a US permanent resident with a Green Card). Questions? Call Jim or Teresa at 877.564.1707. Producer Name* Phone* Email* Date MM slash DD slash YYYY Client Name Date of Birth MM slash DD slash YYYY Gender Male Female Face AmountMax Premium $/yearTypeTermPermanentHas the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)? Yes No Frequency Date of Last Use Type CLIENT Occupation Bank in U.S. mainland? Yes No Income: Company: Location of work and duties: U.S. Visa type and expiration: Location of primary care physician: Current residence: Primary residence: Location(s) of owned homes: IMMEDIATE RELATIVES WITH U.S. CITIZENSHIP OR GREEN CARD LIVING IN U.S.? Yes No If yes, relation? AssetsTotal WorldlyIn the U.S. OnlyOutside the U.S.LiabilitiesTotal WorldlyIn the U.S. OnlyOutside the U.S.Net WorthTotal WorldlyIn the U.S. OnlyOutside the U.S. TRAVEL: PRIOR 12 MONTHS (list all travel)Click the + sign to add more travel. City/CountryReasonNumber of Trips/DatesTotal Days TRAVEL: NEXT 12 MONTHS (list all travel)Click the + sign to add more travel. City/CountryReasonNumber of Trips/DatesTotal Days INSURANCE: APPLIED FOR COVERAGEType/Face AmountOwner and BeneficiaryLife Insurance CompanyInsurance Need/ReasonINSURANCE: IN-FORCE COVERAGEType/Face AmountDate Policy was IssuedOwner and BeneficiaryLife Insurance CompanyInsurance Need/ReasonFor 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 Δ