Applicant

Life Questionnaire

Applicant info, beneficiaries and health questions. Attachments: up to 10 files, 20 MB in total.

Submission Date11/11/2026

Applicant Info 申请人资料

Last Name 姓*

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First Name 名*

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Birth Place 出生地*

ChinaUSAOthers

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States or Others 省/州份*

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Phone Number 联系电话*

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Email Address 电邮*

Enter a valid email address.

Residence Address 居住地址*

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Mailing Address 邮递地址*

Same 同上Others 其他

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Net Worth 个人资产净值*

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Currency 货币*

USD 美元RMB 人民币

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Employment 就业情况*

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Education 学历optional

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Earned Income (Annual) 年薪*

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Other Income (Annual) 其他收入 (年)optional

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Beneficiaries 受益人资料

Class 类别*

Primary 首选Contingent 备选

Choose one.

Name 姓名*

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Age 年龄*

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Relationship 关系*

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Class 类别optional

Primary 首选Contingent 备选

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Name 姓名optional

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Age 年龄optional

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Relationship 关系optional

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Class 类别optional

Primary 首选Contingent 备选

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Name 姓名optional

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Age 年龄optional

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Relationship 关系optional

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Health Questionnaire 健康调查

Height 身高*

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Weight 体重*

Lbs 磅Kg 公斤

Enter the weight and choose Lbs or Kg.

Cigarette User 是否吸烟*

YesNo

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Last Doctor Visit 上次就诊日期*

Enter the date.

Reason for Last Visit 上次就诊原因*

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Doctor Name 主诊医生姓名*

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Doctor Phone # 主诊医生电话*

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Office Address 主诊医生地址*

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Any Known Diseases 已知疾病optional

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Your Medications 您平时服用的药物optional

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Father 父亲*

Alive 在世Deceased 离世

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Mother 母亲*

Alive 在世Deceased 离世

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Memo 备注optional

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Signature 提交人签名*

Please sign above.

* Required

Submitted

The questionnaire has been sent.