Preliminary Inquiry Form

Complete the following information if you would like to obtain a quote. Please understand this is not an application to apply for life insurance or any other financial product offer. Rather, this only a preliminary inquiry to assist illustration purposes and consider your basic qualifications.  A licensed life insurance agent or other appropriate licensed professional will contact you to complete a formal application following your completion of this form. 

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you. Your information will not be sold or provided to any other entity for marketing or any other purpose.


Basic Pre-Qualifications
To save time, please review the following basic life insurance qualifying details prior to completing the form below. Accordingly, YOU SHOULD NOT PROCEED FURTHER IF… you have any of the following medical or personal difficulties: 1) Cancer, Stroke or Heart attack within the last five years. 2) Recorded history of drug abuse within the last five years. 3) Arrested for drunk driving (DUI) within the last three years. 4) Convicted of a felony within the last five years or are currently on parole. 5) If you are on state disability income (SDI) or General Relief (welfare). 6) If you have Diabetes 1 (Diabetes 2 is acceptable if under control with medication). 7) If you are unemployed and NOT RECEIVING RETIREMENT INCOME. 8) If you have filed for Bankruptcy (Chapter 7 if discharged LESS than one year / Chapter 13 is OK).