Zoe Agency

Secure Client Intake

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Zoe Agency

Confidential Client Intake

Please complete this form so we can prepare your protection review and design the right coverage for your household.

Confidentiality & Data Handling

The information you provide is used only for underwriting, case design, and policy placement. Your data is transmitted securely to your assigned agent. This form auto-saves progress locally in your browser and clears when you close this tab. Only complete this form on a personal device.

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Family

Work

Beneficiary

Health & Finance

Review

Step 1 of 6

Getting Started

Tell us which coverage type we are reviewing, then share your personal information.

Coverage Type

This determines which sections of the form apply to you.

Life Insurance Whole life, IUL, or term review Annuity FIA or income-focused review

Client Information

Basic identification for underwriting.

First Name *

Last Name *

Date of Birth *

Place of Birth *City, State or Country

Social Security Number *Stored securely. Format XXX-XX-XXXX

Phone *

Email *

Height *Feet and inches (e.g. 5'10")

Weight *Pounds

Driver's License Number *

License Expiration Date *

Step 2 of 6

Residence & Family

Your address and dependent children, if any.

Residence

Where you currently live.

Home Address *Street, city, state, zip

Years at Address *

Children

List each child who may need coverage or be listed as a contingent beneficiary. Skip if none.

Step 3 of 6

Employment & Income

Your work history and household income.

Employment

Employer or Business Name & Address *

Years with Employer or Business *

Occupation or Title *

Job Duties *Brief description of what you do day to day

Income

Your personal earnings and total household income.

Your Annual Income *

Total Household Income *All earners in the home

Step 4 of 6

Beneficiaries

The person or people who receive proceeds on the death benefit. Name a primary and a contingent so there is no gap.

Primary Beneficiary

The first in line to receive proceeds.

Full Name *

Relationship *

Date of Birth *

Social Security NumberRequired only for annuity applications

Address

Contingent Beneficiary

The backup if the primary is unavailable.

Full Name

Relationship

Date of Birth

Social Security NumberRequired only for annuity applications

Address

Step 5 of 6

Health & Finance

Medical, banking, and background information required for underwriting.

Medical

Required for life insurance underwriting. Not requested for annuity applications.

Primary Doctor or Hospital

Doctor Phone

Doctor or Hospital Address

Date of Last Visit

Reason for Last Visit

Result of Last Visit

Do you smoke or use tobacco or nicotine?

Any medical conditions?Diabetes, high blood pressure, high cholesterol, heart, cancer, other

Describe condition(s)

Do you take any prescription medication?

Medication Name

Dosage

Frequency

Bank Information

For premium draft. Not requested for annuity applications, which use separate funding instructions.

Bank Name

Account Number

Routing Number

Account Type

Legal Background

Standard underwriting disclosure.

Have you ever had a felony, bankruptcy, or misdemeanor?

Please explain

Step 6 of 6

Existing Coverage & Review

Any coverage you already own outside of employer benefits, then a final review before submission.

Existing Policies

Individual coverage you already own, not coverage provided through an employer.

Review Your Information

Ready to Submit

Your agent will receive this intake and prepare your review. If you would like to keep a copy for yourself, use Download a Copy.

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Thank You

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