Coverage Review Intake

Step 1: Personal Information

Legal Name * DOB * Email Address * Phone # * Gender Driver’s License # Address *

Step 2: Coverage, Insurance & Work

Coverage Requested / Product Type Existing Personal Life Insurance Do not include work-provided insurance. Beneficiaries & Relationship Occupation Name of Employer Annual Income Smoker (Y/N) *

Step 3: Health Information

Major Traffic Violations - Last 3 Years Family Doctor Last Doctor Visit Any Medical Conditions & When Major Surgeries Only & When Medications Currently Being Taken Height & Weight Parents/Siblings heart disease or cancer before age 60?

Step 4: Review & Submit

Review the filled sheet below. When you submit, Johnny will receive a clean completed PDF by email.

Welcome to Your Coverage Review

Let’s Get You Ready

Step 1: Personal Information

Step 2: Coverage, Insurance & Work

Step 3: Health Information

Step 4: Review & Submit