Pre-Qualification Questionnaire

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Insurance Program

Completing this form will:

1) Pre-qualify you for the Affordable reduced rates to see what part of the program you qualify for. There is never a physical exam to qualify.

2) Reduce the time needed in determining the best plans you can qualify for.

Please be as open and honest in your answers so we can provide you with the most accurate insurance rates. Upon completion, you will have the option to continue your application with or without an agent.
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First Name & Last Name* This field is required.
First Name
Last Name
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Phone Number* This field is required.
Area Code
Phone Number
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Email* This field is required.
example@example.com
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Birthday* This field is required.
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Are you a legal resident of the United States? ** This field is required.
Yes
No
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How much Life Insurance Coverage do you need?
$5,000 - $10,000
$10,000 - $20,000
$20,000 - $30,000
$30,000 - $40,000
$50,000+
Other
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Gender* This field is required.
Please Select
Please Select
Male
Female
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What State do you reside?* This field is required.
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Tobacco Use / Have you smoked cigarettes/tobacco in the last 12 months?* This field is required.
Please Select
Please Select
Yes
No
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Primary Beneficiary #1- Who would be the primary person responsible for making your final decisions and paying for the cost associated with your funeral if something were to happen to you tomorrow?* This field is required.
First & Last name
DOB
Female/Male
Relationship
Primary #1
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#2
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#3
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#4
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#5
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#6
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Row 5, Column 3
Primary #1
#2
#3
#4
#5
#6
First & Last name
Row 0, Column 0
DOB
Row 0, Column 1
Female/Male
Row 0, Column 2
Relationship
Row 0, Column 3
First & Last name
Row 1, Column 0
DOB
Row 1, Column 1
Female/Male
Row 1, Column 2
Relationship
Row 1, Column 3
First & Last name
Row 2, Column 0
DOB
Row 2, Column 1
Female/Male
Row 2, Column 2
Relationship
Row 2, Column 3
First & Last name
Row 3, Column 0
DOB
Row 3, Column 1
Female/Male
Row 3, Column 2
Relationship
Row 3, Column 3
First & Last name
Row 4, Column 0
DOB
Row 4, Column 1
Female/Male
Row 4, Column 2
Relationship
Row 4, Column 3
First & Last name
Row 5, Column 0
DOB
Row 5, Column 1
Female/Male
Row 5, Column 2
Relationship
Row 5, Column 3
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Height* This field is required.
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Weight* This field is required.
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Any Medical Diagnoses In the last 5-10 Years? Check all that applies* This field is required.
Have You Been Diagnosed with Diabetes?
Have you ever had Cancer
Within the past 2 years, have you been advised by a physician to have medical tests or examinations to diagnose a possible malignancy but not yet done so?
Have you ever had a Heart Attack, Bypass Surgery, Stent Surgery, Angina, Pacemaker, Defibrillator, Stroke, Seizure, Aneurism?
Congestive Heart Failure
Have you ever had any Kidney insufficiency? Dialysis? Cirrhosis? Hepatitis?
In the past 10 years have you been diagnosed/treated for AIDS/HIV
Lupus? Multiple Sclerosis? Parkinson’s? Lou Gehrig’s?
Have you ever been diagnosed or received treatment for Lung Disease? COPD, Emphysema or Asthma?
Have you ever been diagnosed or received treatment for Depression, Bipolar Disorder, Schizophrenia, Alzheimer’s or Dementia? *
Have you had to spend the night in the hospital in the past 3 years?
Other
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Which one? Years since last one?
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Any medication prescribed in the last 5-10 years, including oxygen or inhalers* This field is required.Beyond the health questionnaire, the biggest determining factors of qualifying for the insurance program is what’s on your pharmacy report. As a licensed field underwriter, I know what medications insurance companies will and won’t take. If you have to, please go to your medicine cabinet and provide all the information below.
Yes
No
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Please Provide a List of Your Current Medications, Dosages, and Years Taken (Ball Park is Fine)
Please list all medications and dosages here.
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Do you have any active life or burial insurance in place?* This field is required.
Yes
No
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If Yes: What Amount? What Company? Monthly Payments? Will this replace any coverage or add on to it?
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What do you want life insurance to do for you? (Select all that apply)
Provide Extra Coverage
Leave Something Behind For My Family.
Peace of Mind
Cover Burial Expense
Future Planning for my Children/Grandchildren
Retirement Solutions
I have questions about the Cash Value inside a life policy.
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How long do you want to be protected?
10 years
20 years
30 years
Lifetime
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Select the personal coverage you're most interested in
Term Life (temporary coverage, expires 10-30 years)
Term w/ Return Of Premium (Get your money back if you outlive the policy)
Whole Life & Final Expense (permanent)
Cancer Coverage
Free Life Insurance -$3000 Accidental Insurance
Other
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How soon are you looking for coverage?* This field is required.
Please Select
Please Select
Immediately
1-2 Weeks
30 Days
We offer a 30 day FREE look period. If you decide you want to raise or lower the coverage you can do that without having to re-qualify.
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Are you looking to insure anyone else? (i.e. spouse, kids, parents etc)
First & Last name
DOB
Female/Male
Relationship
SSN#
Insured #1
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Row 0, Column 1
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Row 0, Column 4
Insured #2
Row 1, Column 0
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Insured #3
Row 2, Column 0
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Insured #4
Row 3, Column 0
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Insured #5
Row 4, Column 0
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Row 4, Column 4
Insured #6
Row 5, Column 0
Row 5, Column 1
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Row 5, Column 3
Row 5, Column 4
Insured #1
Insured #2
Insured #3
Insured #4
Insured #5
Insured #6
First & Last name
Row 0, Column 0
DOB
Row 0, Column 1
Female/Male
Row 0, Column 2
Relationship
Row 0, Column 3
SSN#
Row 0, Column 4
First & Last name
Row 1, Column 0
DOB
Row 1, Column 1
Female/Male
Row 1, Column 2
Relationship
Row 1, Column 3
SSN#
Row 1, Column 4
First & Last name
Row 2, Column 0
DOB
Row 2, Column 1
Female/Male
Row 2, Column 2
Relationship
Row 2, Column 3
SSN#
Row 2, Column 4
First & Last name
Row 3, Column 0
DOB
Row 3, Column 1
Female/Male
Row 3, Column 2
Relationship
Row 3, Column 3
SSN#
Row 3, Column 4
First & Last name
Row 4, Column 0
DOB
Row 4, Column 1
Female/Male
Row 4, Column 2
Relationship
Row 4, Column 3
SSN#
Row 4, Column 4
First & Last name
Row 5, Column 0
DOB
Row 5, Column 1
Female/Male
Row 5, Column 2
Relationship
Row 5, Column 3
SSN#
Row 5, Column 4
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Do you have a valid checking or savings account in the US?* This field is required.
Checking
Saving
Other
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Will anyone other than yourself be paying for this program?* This field is required.
Yes
No
Other
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Continue Without An Agent or Book An Appointment Time Below

If you would like to continue without an agent click "Instant Approval" to complete the quick and easy application. Have coverage in as little as 5 minutes.

If you would like to continue with an agent booked an appointment time below. We will contact you at the time you requested to review your options.

If You Have Questions prior to your appointment Call Or Text us @ 470-524-1119

Looking Forward To Talking To You Soon!
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Let's Have A Conversation (optional)If you have any questions or would like us to continue your application with a phone call, please choose the date and time that works best for you.
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