Pre-Application Questionnaire

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Additional Information

Do any of the following apply?

  • Your professional or occupational license or certification has ever been suspended, revoked, restricted, inactivated, surrendered, or the like.
  • There is a pending investigation or complaint concerning you with a regulatory, governmental, or other entity that oversees your profession.
  • You have been disbarred; or
  • You have ever been fined or sanctioned by an entity that oversees your profession.

Daniel Mensh
(336) 624-3853
Email me

We value your privacy. Due to the confidential nature of the questions being asked, we limit the amount of time that we maintain your information. Once you complete the questionnaire, your answers are delivered securely to your agent, who will complete your official application and send to you securely for your review and signature.

Please call your agent, Daniel Mensh at (336) 624-3853 with any questions. Thank you for working with us on your coverage.

Disability Quotes is an independent agency authorized to offer products of The Guardian Life Insurance Company of America (Guardian), New York, NY and its subsidiaries, and is not an affiliate or subsidiary of Guardian. The Guardian Logo is a registered service mark of Guardian, used with permission.