Mortgage Protection Questionnaire

Please fill out the following form so we can work your mortgage protection insurance options. Please answer the questions as best as you can.

First name

Last name

Phone

Address

How much do you own on your mortgage/home equity loan/other loan?

What is your mortgage payment with taxes and insurance?

How many years is your mortgage for?

Are you paying anything additional towards the principal? If so, how much additional?

Why are you interested in Mortgage Protection Insurance and what do you want it to do for you?

What is your date of birth?

Have you used any nicotine or toacco in the last 3 years? If so, what type do you use (cigaretts, dip, chew, vap/e-cigs). If quite, when?

Please provide the names of any prescriptions that you take along with the reason you take them and how long you have taken them? If none, type none

Have you ever had any major health problems? You know like big things… like heart problems, stroke, cancer, lung, kidney, memory problems, or any major surgeries? Please provide details of the diagnosis, when diagnosed, and if being treated, what are you being treated with (medications, therapy, other? If none, type none.

In the last 10 years, have you ever had any DWI/DUI’s, Felonies, Probation, Parole, Suspended Driver’s License, or a lot of speeding tickets? If yes, please provide details of when and what? If none, type none.

What is your height and weight?

What is your gender?

What is your occupation? If not, working please provide details? Are you receving disability income? If so, please provide details? If on disability, can you all the ADL's? If not, please explain?

What agent are you working with?

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Thanks for submitting! We will be in contact with you soon!