Life Insurance Tax Reporting Questionnaire

Life Insurance Tax Reporting Questionnaire
Please complete this questionnaire to assist with accurate tax reporting of your life insurance policies.
Full Name
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Are you the policyholder or completing this on behalf of someone else?

Life Insurance Policy Details

Rows	Insurance Company	Policy Number	Policy Type	Policy Start Date	Policy End Date (if applicable)
Policy 1
Policy 2
Policy 3

Did you pay any life insurance premiums during the tax year?
Total Premiums Paid During the Tax Year (USD)
Have you received any distributions, loans, or withdrawals from your life insurance policy during the tax year?
Please list the beneficiaries of your life insurance policy.
Are you a tax resident of more than one country?
Do you own or are you the beneficiary of a foreign life insurance policy?
If you have a tax advisor or accountant, please provide their name and contact information.
Should be Empty:

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