Key Person Coverage Insurance

Your key employees are your most valuable business asset. Their skill, knowledge and experience are your real profit makers. Without them, the success and growth of your business could be in jeopardy. Key employee insurance is designed to protect your business from the adversities associated with the loss of a key employee, manager or executive. The death or disability of a key employee could result in a substantial financial loss due to hiring and training a replacement, lost sales, and/or slowed production.

Full Name*
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Information About You & Your Spouse
Please enter information below for all to be covered
Your Information
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Marital Status
Occupation
Height
Weight
Smoker
Have you had any of the following health conditions
- None
- Heart
- Cancer
- Diabetes
- HBP
Spouse Information
Name
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Marital Status
Occupation
Height
Weight
Smoker
Have you had any of the following health conditions
- None
- Heart
- Cancer
- Diabetes
- HBP
Medical Background
Have you used any form of tobacco products? (cigarettes, pipe, chew, nicotine gum or patches)
Past 36 Months?
Past 60 Months?
Have you ever been rated or declined for life insurance?
If Yes, Why?
Have you ever been treated for high blood pressure or cholesterol?
Has any member of your family (parent or sibling) died from coronary artery disease prior to age 60?
Is there a family history of colon or prostate cancer (for male applicant) or breast, ovarian, or colon cancer (female applicant) in a parent or sibling prior to age 60?
Are you currently taking or have you been advised to take any prescription medications?
If Yes, Why?
Have you had a DUI / reckless driving conviction in past 5 years or 3 moving violations in the past 3 years?
Life Coverages
Coverage for Self
Amount of Coverage ($)
Type of Coverage
Disability Income
Long Term Care
Coverage for Spouse
Amount of Coverage ($)
Type of Coverage
Disability Income
Long Term Care
Final Questions/Comments
Comments / Remarks

Key Person Coverage Insurance

Key Person Coverage Insurance

Key Person Coverage Insurance

Information About You & Your Spouse

Your Information

Spouse Information

Medical Background

Have you used any form of tobacco products? (cigarettes, pipe, chew, nicotine gum or patches)

Life Coverages

Coverage for Self

Coverage for Spouse

Final Questions/Comments

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