Pre-Qualification Form

Mortgage Protection Policy is designed to pay off your mortgage loan or help cover your mortgage payments if something unexpected were to happen to you.

Please be as open and honest in your answers so we can provide you with the most accurate rates.
Borrowers Name:*

First NameLast Name
Is there a Co-Borrower:

YesNo
Borrower Age:
Lender Name
Mortgage Amount *
Borrowers Birthday*
Mortgage Monthly Payments:
Borrower Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Are you a legal resident of the United States? *

YesNo
If you served in the United States military, please indicate your branch of service

U.S. ArmyU.S. NavyU.S. Air ForceU.S. Marine CorpCoast GuardSpace ForceN/A
HEALTH
Tobacco Use / Have you smoked cigarettes/tobacco in the last 12 months?*

Primary Beneficiary #1- Who would you leave the home to if something were to happen to you?*

Rows	First & Last name	DOB	Female/Male	Relationship
Primary #1
#2
#3
#4
#5
#6

Height*
Weight*
Any Medical Diagnoses In the last 5-10 Years? Check all that applies*

Have You Been Diagnosed with Diabetes?Have you ever had CancerWithin 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 FailureHave you ever had any Kidney insufficiency? Dialysis? Cirrhosis? Hepatitis?In the past 10 years have you been diagnosed/treated for AIDS/HIVLupus? 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? *HIV / AIDSHave you had to spend the night in the hospital in the past 3 years?N/A - HealthyOther
Which one? Years since last one? *
Any medication prescribed in the last 5-10 years, including oxygen or inhalers*

YesNo
COVERAGE
Do you have life Insany active life or burial coverage in place?*

YesNo
How long do you want to be protected?
Phone Number*

Area CodePhone Number
Email*
example@example.com
Select the personal coverage you're most interested in

Term Life (Temporary coverage, expires in 10-30 years)Term w/ Return Of Premium (10-30yrs-Get a portion of your money back if you outlive the policy)Whole Life (Lifetime Coverage)Final Expense (Whole Life Ages 45-89)IUL - Retirement Savings requires the minimum investment of $200 -500+ monthlyOther
How soon are you looking for coverage?*
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.

Are you looking to insure anyone else? (i.e. spouse, kids, parents etc)

Rows	First & Last name	DOB	Female/Male	Relationship	SSN#
Insured #1
Insured #2
Insured #3
Insured #4
Insured #5
Insured #6

Do you have a valid checking or savings account in the US?*

CheckingSavingOther
Mortgage Protection Phone Appointment
Should be Empty:

HEALTH

COVERAGE