Pre Qualify Life Insurance
Welcome! Lets get you started on your free quote. The information below will help in my research finding the right options for you. Please reach out with any questions.
Full Name
First Name
Last Name
What is your DOB (month, day, year)
What is your gender?
Please Select
Male
Female
N/A
Height and weight
Height
Weight
Address
Street
City, zip
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Do you use any kind of tobacco or have you ever used them?
Please Select
No
Yes
If yes, what kind of tobacco products? How long have you used or been using them?
Check the conditions that apply to you:
Asthma
Cancer
Cardiac Disease
Diabetes
High Cholesterol
Depression
Drug or Alcohol abuse
Anxiety
COPD
High Blood Pressure
Rheumatoid Arthritis
Sleep Apnea
Bipolar
Schizophrenia
Other
If yes to high blood pressure or diabetes, please let me know the last reading, when that was and if you are type 1 or 2 or on insulin. If you know when you were diagnosed with diabetes or started taking insulin, this is helpful as well.
Are you currently taking any medication?
Yes
No
Please list current medications. Additionally it's helpful to know any medications prescribed within the last 10 years even if you’re not taking them anymore or never filled them.
Any surgeries or hospitalizations in the past 10years?
Yes
No
Please list them, it's helpful to know approximately when those occurred if so.
Are you permanently disabled?
Yes
No
If yes, what is the disability for and when did disability begin?
What are your life insurance goals (budget)? For example, you may owe $150,000 on a mortgage so your goal might be to have the mortgage paid off for your family if you were to pass or it might be to cover final expenses such as funeral etc. Another goal might be to obtain as much life insurance as you can with a set amount per month so your family has a less burden and some financial support when you pass, etc.
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