Pre-Qualification Rate Class

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Rate Class Qualification

Corey Schuler
Broker/Independent Agent
National Producer #8430607

Toll Free (866) 679-8376
Local (214) 842-4394
Fax (214) 842-4404

Email: coreys@thetermlifeshop.com
Website: www.thetermlifeshop.com

1) Fill out the questionnaire to isolate an accurate rating class (or speak to us on the phone).
2) Be matched up with the best carrier and product based on your unique profile.
3) Apply via email or over the phone with me.

Email *

Name (First, Middle Initial, Last) *

Amount of coverage desired? Term length desired. *

Gender *

Male

Female

Height *

Weight *

Zip Code *

Date of Birth *

YYYY

Phone Number *

Are you a legal resident of the United States? *

Yes

Permanent Resident (green card holder)

Visa

Have you ever used any form of tobacco (cigarettes, cigars, pipe, chewing tobacco, vape, nicotine patch or gum)? Yes or No. If yes, please list the date that you last used and the type of tobacco. *

Do you participate in recreational marijuana usage? If so, please detail frequency, type (smoke, vape, edibles) and last date of use. If you do not or have never used, type N/A. *

Any other life insurance applications pending? *

Yes

Will this replace other life insurance coverage? *

Yes

Have you ever applied for life insurance that was declined, postponed, or modified in any way? Details.. *

Have you ever received disability benefits for any injury, sickness, or impaired condition? Details... *

Do you engage in any form of motorized racing, scuba diving, parachuting, hang gliding, ballooning, mountain climbing or any other hazardous activity? Details... *

Private pilot? *

Yes

Been charged with or convicted of a felony? Details... *

Yes

In the past 5 years, have you had any speeding tickets, moving violations, or had your license suspended or revoked? Details... *

Have you ever had a DUI/DWI conviction? If yes, please list the date of occurence. *

Any intentions of traveling outside of the US or Canada in the next two years? *

Yes

In the past 10 years, have you had any problems with alcohol or substance abuse? If so, please list date of last use, and any details regarding treatment. If not, answer NO. *

Who will be the beneficiary of this policy? List name and relationship to you. *

Do you belong to any active military or naval organizaion? *

Yes

Have you ever filed for bankruptcy? If so, please list the date, Chapter type, has it been discharged? details... *

Do you take any prescription medications? If yes, please list the name, what they treat, dosage, and how long you have taken them for. If no, type No. *

Recent Blood Pressure Reading, or type no if unsure: *

Recent Cholesterol Numbers-total, ratio if known, or type no if not sure *

Family Health History-age of mother if living, or list age when deceased and cause of death *

Family Health History-age of father if living, or list age when deceased and cause of death *

Family Health History-age of brothers/sisters if living, or list their age(s) when deceased and cause of death *

Occupation *

Did your mother, father, brothers or sisters, have heart disease, stroke, cancer, or diabetes before age 60? Details..or No if they did not. *

Any surgeries or test results pending or recommended that have not been completed? *

Yes

Do you have a sleep apnea diagnosis? If yes, do you recall if they rated it as mild, moderate or severe? Any other details that you could share.. *

Have you ever had gestational diabetes? If so, how long ago? *

Any other relevant medical history (including prior hospitalizations or surgeries) that may effect your insurability that we should know about? Please explain or if no, type No. *

Send me a copy of my responses.

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