Confidential Preliminary Questionnaire

Please fill in the answers to all fields.


Demographic Information




Yes    No 





Employment Information









Contact Information












Annual    Semi-Annual    Quarterly    Monthly 

Policy Owner






Beneficiary(ies)








Term Life 10 Year    15 Years    20 Year    30 Year    Universal Life to age 100+  


If NONE, check here 






Yes    No 








Yes    No 








Yes    No 








Yes    No 





Personal Information


Yes    No 


Yes    No 


Yes    No 


Yes    No 


Yes    No 


Yes    No 


Yes    No 


Yes    No 


Yes    No 


Yes    No 


I declare that the statements and answers given on this questionnaire are true, correctly recorded to the best of by knowledge and belief.




The answers on this questionnaire will be used to prepare your application form which we will forward to you for your final completion. Evidence of insurability will be required. Coverage is not in effect until a policy is issued, and all delivery forms are signed by the insured and owner and full premiums are paid.


Please enter the Security Code *

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If you’re interested in learning more about obtaining affordable term life insurance, even if you’re considered at-risk, contact us today at (800) 400-5940, ext. 3.

*Premiums illustrated are for male preferred non smoker classification paid monthly preauthorized checking. Annual, Semi Annual and quarterly modes available. Female preferred non smoker rates are lower. Other classes, ages, and face amounts for males and females may be higher or lower and are available upon request. Your actual premiums will vary, depending on your health history, company determined underwriting status, age, height, weight, sex and coverage preferences. All pricing and eligibility subject to underwriting with a paramedical or medical exam. Additional reports from Primary care physicians and specialist may be required. Products may not be available in all jurisdictions. Premiums increase annually beginning in year 11 for Ten year term. In most states, in the event of suicide during the first two policy years, death benefits are limited only to the return of premiums paid. Application resulting in declines or ratings by insurance companies may be reported to MIB. State complaint Insurance buyer guide supplied with each policy.

No insurance is to be consider in force until the insurance applied for, has been approved by the carrier and all delivery forms and payment are received while the insured is alive during the delivery time period allowed by the carrier.

DO NOT CANCEL ANY EXISTING COVERAGE IF APPLICATIONS ARE TO REPLACE UNLESS YOU HAVE RECEIVED, REVIEWED AND ACCEPTED POLICY APPLIED FOR.



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