Adult Life Insurance Questionnaire

Employer Information
Enter employer’s name (or “Retired,” “Student,” or “Homemaker”)*
Employer’s address*
Street Address City State / Province / Region ZIP / Postal Code Country

If Retired/Student/Homemaker, enter your home address
Nature of business*
Job title*
How years at current employer?*
Please only type the number of years
If under 2 years, previous employer’s name*
If under 2 years, previous employer’s address
Street Address City State / Province / Region ZIP / Postal Code Country
Annual Earned Income (Salary, Tips, Commissions, other Income)*
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)*

Primary Beneficiary
Primary beneficiary name*
First Middle Last Suffix
Primary beneficiary date of birth*
MM slash DD slash YYYY
Primary beneficiary address*
Street Address City State / Province / Region ZIP / Postal Code Country
Primary beneficiary relationship to you*

Secondary Beneficiary
Secondary beneficiary name
First Middle Last Suffix
Secondary beneficiary date of birth
MM slash DD slash YYYY
Secondary beneficiary address
Street Address City State / Province / Region ZIP / Postal Code Country
Secondary beneficiary relationship to you
* If you have more than one primary and/or secondary beneficiary, please list below and specify percentages for each. Beneficiaries can be changed/added at any time during and after the application process.
Additional beneficiaries
Additional comments
Name of your IBC Global Agent*
If you do not see your agent above, please specify below*
If you have any questions please call us at 610-681-2655.

IBC GLOBAL – LIFE INSURANCE QUESTIONNAIRE