Lindenhouse Insurance Group Fact Finder & Risk Assessment

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Phone Number* This field is required.

Please enter a valid phone number.

4

State of Residence * This field is required.

5

Which type of life insurance are you most interested in?* This field is required.

Whole Life

Term Life

Indexed Universal Life (IUL)

Mortgage Protection

Not Sure / Need Guidance

6

Tobacco use in the past 12 months?* This field is required.

YESNO

7

Any history of heart attack, stroke, cancer, or other major heart/vascular disease in the past 10 years?* This field is required.

YESNO

8

Currently treated for high blood pressure or cholesterol?* This field is required.

Yes, uncontrolled or multiple meds

Yes, well-controlled

No

9

Any DUI/DWI in the past 5 years?* This field is required.

YESNO

10

Any felony conviction in the past 10 years?* This field is required.

YESNO

11

Any major surgery or hospital stay in the past 2 years?* This field is required.

Yes, related to ongoing illness

Yes, unrelated to ongoing illness

No

12

Any diagnosed chronic illness (e.g., diabetes, COPD, kidney disease)?* This field is required.

Yes, poorly managed or multiple

Yes, well-managed

No

13

Currently taking more than 3 prescription medications?* This field is required.

Yes, for multiple chronic issues

Yes

No

14

Remember your risk class when asked “ In your opinion, how healthy are you?”* This field is required.Risk Class Guide ❤️ Score 36–40 → ❤️❤️❤️❤️❤️ Score 28–35 →❤️❤️❤️❤️ Score 20–27 →❤️❤️❤️ Score 12–19 →❤️❤️ Score 0–11 → ❤️

15

Thank you for completing your Life Insurance Fact Finder & Risk Assessment! Based on your answers, you now have an idea of your likely risk class. Be sure to remember your heart rating ❤️, as it helps determine which products you qualify for.

You’ll be redirected shortly to our Quote & Apply page, where you can:

• See the life insurance products that match your needs

• Compare coverage options side by side

• Start your application quickly and securely

We’re excited to help you take this important step in protecting your family and future.

Next Steps:

1. Keep your heart rating handy.

2. Click the button below to go to your personalized Quote & Apply page.

3. Explore your options, and reach out if you have questions — we’re here to guide you every step of the way.

Taking this step today is more than just filling out a form — it’s a smart, intentional choice for you and your loved ones. We’re here to make the process simple, fast, and worry-free.

— Lindenhouse Insurance Group