Life Insurance Application — Nobleza Insurance Services

👤 Personal Information

Basic information about the person being insured.

Full Legal Name *

Date of Birth *

Sex *

Home Address *

Cell Phone *

Email *

Height / Weight

Marital Status

Place of Birth

U.S. Citizen / Resident?

SSN / ITIN (or provide to agent)

Driver's License / State ID #

ID State / Expiration

💼 Employment & Financial

Carriers use this to confirm insurability and income replacement needs.

Employer / Business Name

Years Employed

Occupation / Job Duties

Annual Earned Income

Estimated Net Worth

Existing Life Insurance? (carrier, coverage amount, type)

👨‍👩‍👧 Beneficiaries

Who should receive the death benefit? We'll need their full name, relationship, date of birth, and percentage.

Primary Beneficiary 1

Relationship

Date of Birth

Share %

All percentages must add up to 100%

Add Contingent Beneficiary (backup)

Contingent Beneficiary 1

Relationship

Date of Birth

Share %

Add Spouse / Child Rider

Full Name

Relationship

Date of Birth

Height / Weight

SSN / ITIN (optional)

🏥 Health Pre-Screen

Quick yes/no questions. Honest answers help us find the best carrier for you.

Do you currently use tobacco, nicotine, or marijuana?

Type & how long ago you quit (if former user)

Have you ever been diagnosed with diabetes?

Type & how it's managed

Any history of heart disease, heart attack, or stroke?

Details & date(s)

Any history of cancer in the last 10 years?

Type & treatment status

Any surgeries or hospitalizations in the last 5 years?

Procedure & date(s)

Are you currently taking any prescription medications?

Medication / Dosage / Reason

Any DUI / DWI in the last 5 years?

Date & details

🏦 Doctor & Payment

Last section before review. Bank info is needed to set up your premium draft.

Primary Care Doctor

Doctor / Clinic Name

Phone

Address

Date Last Seen

Reason for Visit

Any upcoming appointments scheduled?

Details

Payment Information

Bank Name

Account Type

Routing Number

Account Number

Preferred Draft Date

Payment Mode

Is the premium payer the same as the insured?

Yes

No — someone else is paying

✅ Review & Submit

Please confirm your information is accurate before submitting.

I confirm that the information I've provided is accurate and complete to the best of my knowledge.

🎉

Information Received!

Your application information has been sent to your Nobleza agent. They'll reach out within 24 hours to confirm details and next steps.

Questions? Call or text us at (714) 862-2692

Nobleza Insurance Services · CA License #6019417
This form collects information to prepare your insurance application. It is not a binding contract or guarantee of coverage.