Legacy Insurance Agency
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R. Barry Page
R. Page
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Pre-Application Questionnaire
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1
Insured
Information
2
Occupation
Information
3
Financial
Information
4
Additional
Information
5
Coverage &
Health Info
Coverage Health Information
Within the past five years, have you had any application for insurance declined, postponed, modified, rated, cancelled, rescinded, or have you withdrawn a pending application, or had a renewal or reinstatement request refused?
No
Yes
Please provide details
Within the past six months, have you applied for life insurance through The Guardian Life Insurance Company of America ("Guardian") or any other company?
No
Yes
Company Name
Do you have any disability insurance in force, or applied for, or for which you are eligible within the next 12 months with any company? This includes any group LTD that you may have at work
No
Yes
Coverage Details
Insurance Company Name
Is this coverage being replaced?
No
Yes
Type of coverage
Individual DI
Group LTD
Association
Status
In Force
Applied For
Benefit Amount
Employer Paid
No
Yes
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Height
Weight
Please tell us a little about your overall health