90-Second Pre-Qualification Survey
WILGEN Group & Associates
Name
*
First Name
Last Name
Home Address
*
Street Address
Street Address Line 2
City
State
Zip Code
What is your date of birth?
*
-
Month
-
Day
Year
Date
What is your gender?
*
Please Select
Male
Female
N/A
What is your cellphone number?
*
What is your email address?
*
example@example.com
How much do you weight?
*
What is your height (in inches)?
*
Do you have any dependent children under the age of 18?
*
Yes
No
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Next
If you died unexpectedly tomorrow, what debts would you not want your beneficiary to worry about (choose as many as you want)?
*
Student Loans
Auto Loans
Credit Cards
Mortgage
Future Education
Misc.
None
What is the estimated total amount from the previous question?
*
How long do you want to be covered with life insurance?
*
10-20 Years
20-30 Years
Lifetime
Do you currently have a life insurance policy outside of what your employer provides?
*
Yes
No
N/A
Have you ever lived outside of the U.S. or plan to do so in the next 2-years?
*
Yes
No
Have you ever had a felony or currently on parole?
*
Yes
No
Have you ever plead guilty of DWI/DUI or had your driver's license suspended?
*
Yes
No
In the past 5-years, have you plead guilty to a driving moving violation?
*
Yes
No
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Next
Do you engage in any extreme recreational activities (e.g. motor/vehicle racing, mountain/rock climbing, scuba/sky diving, student pilot, etc.)?
*
Yes
No
How often do you consume alcohol?
*
Never
Daily
Weekly
Monthly
Occasionally
Within the past 5-years, have you been advised to receive treatment or counseling to discontinue the use of alcohol or any controlled substances?
*
No. Both.
Yes. Alcohol
Yes. Controlled Substances
Yes. Both
In the past 12-months, have you used any forms of tobacco or nicotine?
*
N/A
Cigarettes
E-Cigarettes
Vape
Chew / Snuff
Cigars
Nicotine Gum/Patches
In the past 5-years, have you used any forms of marijuana (not to include for medical use) or heroin, cocaine, narcotics, barbiturates, hallucinogens, or any controlled substances?
*
Yes
No
Within the past 5-years, have you been advised to have any of the following (do not include routine checkups)?
*
N/A
EKG
CT Scan
Bone Scan
Colonoscopy
Within the past 5-10-years, check the conditions (if any) that you have been diagnosed:
*
N/A
Asthma
Cancer (other than skin)
Cardiac disease
Diabetes
Hypertension
Psychiatric Disorder
Epilepsy
Sleep Apnea
Seizures
Stroke
Congestive Heart Failure
Heart Attack
Dementia
Alzheimer's
Anxiety
ALS
Muscular Dystrophy
HIV/AIDS
High Blood Pressure
Blood Disorder
Coronary Artery Disease
Heart Murmur
Irregular Heartbeat
Tumor
Gastrointestinal Bleeding
Chronic Obstructive Pulmonary Disease
Multiple Sclerosis
Parkinson's Disease
Lou Gehrig's Disease
Fibromyalgia
Depression
Bi-Polar Disorder
Crohn's Disease
Lupus
Have you had a parent or sibling pass away prior to age 60 from cardiovascular disease or cancer (breast, colon, ovarian, prostate, pancreatic, etc.)?
*
Yes
No
Are you currently taking prescription medicine?
*
Yes
No
If you answered "yes" above, what is the name of the medicine, dosage, and frequency?
Do you have a primary care provider?
*
Yes
No
If you answered "yes" above, what is the name, city, state, and phone number of your primary care provider?
Have you ever been denied life insurance?
*
Yes
No
Do you currently have an annuity or life insurance pending or in force?
*
Yes
No
Will coverage be discontinued or reduced, or premium payments stopped, on existing life insurance coverage or an annuity, if the insurance applied for issued?
*
Yes
No
What is your current job title?
*
How long have you worked at your current job?
*
What is your annual income?
*
What is your monthly budget to begin your life insurance program?
*
Who, from WILGEN Group & Associates sent you this survey?
*
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