Easy: I Need A Fillable PDF Created
Budget: $10 – $30 USD
I need help to create a fillable document for my assistant (hopefully no more than two pages. She will use this form herself but may also email it to clients for them to complete (that's why I want it to look more professional than what I could do.)
Our logo is attached. I'm hoping to get two sections of content: first will be the initial data she collects, then if necessary, additional fields of data. Here's the fields/drop-downs, etc. that I want:
First Section
Full Name
Date Of Birth (can be written as "DOB")
Gender: Male or Female (see the image attached "Option Example"...I'm hoping it can be similar)
State:
Term Length: 10, 15, 20, 25, 30 (maybe similar to the "Option Example" and multiple can be selected)
Death Benefit: (this one is a dollar amount)
Smoker: (a "yes or no" or one similar to "Option Example" with "smoker non-smoker")
Health Rating: Super Preferred, Preferred, Standard (multiple can be selected)
Second Section
Street Address:
City:
Zip Code:
Email Address:
US Citizen: (another yes or no)
Social Security Number:
State of Birth:
Driver's License Number:
Driver's License State:
Preferred Phone Number:
Best Time to Call: a.m. or p.m.
Annual Gross Income:
Approx. Net Worth:
Electronic Policy Delivery: yes or no
Mode of Premium Payment: Annual, Semi-Annual, Quarterly, Monthly (can only select one)
Have you ever had a life insurance application decline, postponed, rated or cancelled?: yes or no
Will this replace or modify any existing life insurance?: yes or no
-If yes: Company Name, Policy Number, Face Amount, Year Issued
Is there any application for any other life insurance on the life of the Proposed Insured now pending or being
considered with this or any other company? yes or no
Owner Information: Proposed Insured or Other Than Proposed Insured (see attachment "Owner Information Example)
Beneficiary Information: (see attachment "Beneficiary Information Example")
Special Remarks: (small box for any necessary comments/notes)
Hopefully, you can help me.
Our logo is attached. I'm hoping to get two sections of content: first will be the initial data she collects, then if necessary, additional fields of data. Here's the fields/drop-downs, etc. that I want:
First Section
Full Name
Date Of Birth (can be written as "DOB")
Gender: Male or Female (see the image attached "Option Example"...I'm hoping it can be similar)
State:
Term Length: 10, 15, 20, 25, 30 (maybe similar to the "Option Example" and multiple can be selected)
Death Benefit: (this one is a dollar amount)
Smoker: (a "yes or no" or one similar to "Option Example" with "smoker non-smoker")
Health Rating: Super Preferred, Preferred, Standard (multiple can be selected)
Second Section
Street Address:
City:
Zip Code:
Email Address:
US Citizen: (another yes or no)
Social Security Number:
State of Birth:
Driver's License Number:
Driver's License State:
Preferred Phone Number:
Best Time to Call: a.m. or p.m.
Annual Gross Income:
Approx. Net Worth:
Electronic Policy Delivery: yes or no
Mode of Premium Payment: Annual, Semi-Annual, Quarterly, Monthly (can only select one)
Have you ever had a life insurance application decline, postponed, rated or cancelled?: yes or no
Will this replace or modify any existing life insurance?: yes or no
-If yes: Company Name, Policy Number, Face Amount, Year Issued
Is there any application for any other life insurance on the life of the Proposed Insured now pending or being
considered with this or any other company? yes or no
Owner Information: Proposed Insured or Other Than Proposed Insured (see attachment "Owner Information Example)
Beneficiary Information: (see attachment "Beneficiary Information Example")
Special Remarks: (small box for any necessary comments/notes)
Hopefully, you can help me.