Moseleymcgill – Foreign National

Foreign National Questionnaire
Please 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 Amount
Max Premium $/year
Type
Has 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?
Assets
Total Worldly In the U.S. Only Outside the U.S.
Liabilities
Total Worldly In the U.S. Only Outside the U.S.
Net Worth
Total Worldly In the U.S. Only Outside the U.S.

TRAVEL: PRIOR 12 MONTHS (list all travel)

Click the + sign to add more travel.

City/Country	Reason	Number of Trips/Dates	Total Days

TRAVEL: NEXT 12 MONTHS (list all travel)

Click the + sign to add more travel.

City/Country	Reason	Number of Trips/Dates	Total Days

INSURANCE: APPLIED FOR COVERAGE
Type/Face Amount Owner and Beneficiary Life Insurance Company Insurance Need/Reason
INSURANCE: IN-FORCE COVERAGE
Type/Face Amount Date Policy was Issued Owner and Beneficiary Life Insurance Company Insurance Need/Reason
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

Foreign National