IUL Prequalification Form

IUL Prequalification Form

Please complete this form to determine your preliminary eligibility for Indexed Universal Life (IUL) insurance.
Section 1. Personal Information
Full Name

First NameLast Name
State of Residence
Date of Birth

MonthDayYear
Date
Gender
Marital Status
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Section 2. Financial Qualification
Annual Income:
Employment Status:
Do you have any existing life insurance policies?
List any retirement accounts you currently contribute to. Please select all that apply:
Estimated Net Worth:
Are you comfortable with the potential risks and rewards of an IUL policy?
Section 3. Health Qualification
Do you smoke?
Have you been diaognosed with any chronic illnesses?
If Yes, please specify:
Have you been hospitalized in the last 5 years or had any major medical concerns in the last 5 years ?
If Yes, please specify:
Do you take prescription drugs on a regular basis?
If Yes, please specify:
Do you partake in any high-risk activities, such as exptreme sports?
Section 4. Consent and Submission
By submitting this form, you consent to having your information reviewed for the purpose of determining eligilbility for an IUL policy.
Please click on your option:
Should be Empty:

Section 1. Personal Information