IBC Questionnaire

IBC GLOBAL LLC - LIFE INSURANCE QUESTIONNAIRE

(Please answer ALL sections completely)

Full Name (required)

Date of Birth: (required)

Place of Birth (State or Country)

Social Security Number:

Primary Residence Address: (required)

Address Line 2:

City: (required)

State: (required)

Zip: (required)

Country: (required)

How Long At Present Address?: (required)

Under 2 Yrs, Previous Address:

Country: (required)

Preferred Phone Number

Your Email (required)

Driver's License #/State:

Driver's License Expiration Date:

US Citizen? (required)
YesNo

VISA # and Exp Date if NO to US Citizen:

Do you have current Life Insurance in force? If YES, please describe in detail below. (Company, Amount, Year Issued, Type of Insurance)Insurance, please type NO in the box below. (required)

Do you have a current Policy? if Yes, Provide the Policy Number. (required)

Are you replacing any existing insurance policy(s)? If YES, provide information on which one is being replaced. (Company Name/Date of Issue/Face Amount)

How much do you want to send Monthly to your Policy:

VISA # and Exp Date if NO to US Citizen:

VISA # and Exp Date if NO to US Citizen:

Personal History Questions:

Currently Disabled? (required)
YesNo

Any Tobacco Use over the past 2 years? (required)
YesNo

If YES, type/frequency of tobacco used?

Have you ever been convicted for a felony? (required)
YesNo

Have you been convicted for a DWI or DUI in the past 5 years? (required)
YesNo

Have you been in a car accident where you were found at fault and CITED in the past 3 years? (required)
YesNo

Do you anticipate any BOOKED foreign travel over the next 2 years? (required)
YesNo

If YES, please describe which city and country, the reason for your trip and dates:

Are you enlisted or intend on joining the Military? (required)
YesNo

If YES, Provide Status/Branch:

Are you or do you plan on becoming a licensed pilot? (required)
YesNo

Do you participate in any extreme sports such as Bungee jumping, Rock climbing, racing cars, Scuba Diving, Parachuting, or anything "exteme"? (required)
YesNo

Primary Doctor

Doctors Name:

Address:

Address Line 2:

City:

State:

Zip:

Country:

Phone Number

Date last seen:

Describe below the reason for your visit or treatment given:

Employer Information

*Note: If retired, type N/A under the fields below that do not apply to you

Employer Name or Retired:

Address:

Address Line 2:

City:

State:

Zip:

Country:

Occupation:

Title:

How Long at Current Employer?

Annual Earned Income (Salary, Tips, Commissions, other Income) (required)

Annual Unearned Income (Interest from Stocks, Bonds, Investments, Rents, etc.)

Total Assets (Cash, Savings & Checking Accounts, Cars, Equity in Home, Valuables, etc)

Total Liabilities (Debts, Mortgage, Credit Cards, Bank Loans) (required)

Primary Beneficiary

Primary Beneficiary Name

Date of Birth

Address:

City:

State:

Zip:

Country:

Relationship To You:

Secondary Beneficiary Name

Secondary Beneficiary Name

Date of Birth

Address:

Address Line 2:

City:

State:

Zip:

Country:

Relationship To You:

Additional Beneficiaries:

Additional Comments:

Name of your Agent: