Client Information — National Life Group | PFA

Client Information Form

Please complete all sections accurately. This information is used for policy underwriting and financial planning purposes.

Secure & Confidential — Not for Public Distribution

Personal Info

Financial

Beneficiaries

Medical & Policy

Personal Information

Basic identification and contact details

Legal Name (Last, First)

Gender

Date of Birth

Height

Weight

Contact

Phone #

Email Address

Residential Address

Identification

SSN #

US Citizen?

Country of Birth

Driver's License #

Employment

Employer Name / Address

Occupation

Employed Since (MM/YY)

Financial Information

Income, net worth, and banking details

Annual Income

Net Worth

Household Income

Household Net Worth

Banking

Face Amount

Name of Bank

Account Number

Beneficiary Information

Designate up to two beneficiaries

Primary Beneficiary Beneficiary 1

Full Name

Relationship

Percentage %

Date of Birth

Residential Address

Secondary Beneficiary Beneficiary 2

Full Name

Relationship

Percentage %

Date of Birth

Residential Address

Medical & Policy History

Health background, existing coverage, and physician details

Health Background

Any Special Lifestyle / Smoking?

Any Chronic Care Medical History?

Any Special Medical History?

Family History

Father's Age (or age at death)

Father — Cause of Death (if applicable)

Mother's Age (or age at death)

Mother — Cause of Death (if applicable)

Existing Life Policy

Existing Life Policy?

Company Name

Policy Number #

Face Amount

Date Issued

Physician

Physician Name

Physician Address

Last Consulted (MM/YYYY)

Outcome / Notes

Form Submitted Successfully

The client information has been received and is now on file for internal review. A confirmation will be sent to the email on record.

Date Submitted

NLG / PFAProcessing Team

InternalUse Only