Life Insurance Coverage Intake | BrightSecure Legacy Builders

This form collects the essential information needed to review your options and prepare an accurate life insurance policy. Please complete all sections honestly and to the best of your knowledge. All information provided is kept confidential and used solely for policy review, underwriting, and coverage recommendations.

Life Insurance Coverage Intake Form

Complete all sections below. A licensed agent will contact you within 24 hours to discuss your coverage options.

Policy Information

Will the insured person also be the owner of the policy? *

Insured Person Information

First Name *

Last Name *

Gender *

Date of Birth *

Phone *

Email *

Address *

City *

State *

Zip Code *

SSN (for verification purposes, NO CREDIT CHECK) *

Upload Your Drivers License *

Tap to upload your drivers license

Upload File

Height *

Weight *

Health Information

Do you take any medication? *

Yes No

Have you ever been diagnosed with an illness from a medical doctor? *

Yes No

Employment and Financial Information

Occupation *

Employer Name *

Annual Salary *

Bank Name *

Bank Routing Number *

Bank Account Number *

Do you want to start the policy right away and have the payment withdrawn from your account? *

What day of the month would you like your monthly premium withdrawn? *

Beneficiary Information

Beneficiary First Name *

Beneficiary Last Name *

Relationship to You *

Beneficiary Date of Birth *

Beneficiary Social Security Number *

Children's Information (Optional)

Child 1

First Name

Last Name

Birthdate

Social Security Number

Additional Information

Child 2

First Name

Last Name

Birthdate

Social Security Number

Additional Information

Child 3

First Name

Last Name

Birthdate

Social Security Number

Additional Information

Child 4

First Name

Last Name

Birthdate

Social Security Number

Additional Information

A licensed agent will review your information and reach out within 24 hours.

Application Received.

Thank you. A licensed agent will review your information and reach out within 24 hours to discuss your coverage options. Your family's protection matters.

Protect What You'reBuilding.

Life Insurance Coverage Intake Form

Application Received.

Protect What You're
Building.