EApps

Financial Information

Are you applying for Disability Insurance, Life Insurance, or Both?

Net Worth

For purposes of this section only, Earned Income means the income you are required to report to the Internal Revenue Service (“IRS”) for income tax purposes. This includes W-2 wages, salary, bonuses, your share of net business income, and all other compensation you received for work or services.

Current Income This Calendar Year

Earned Income Actually filed with the IRS last Year.

Earned Income Actually Filed with the IRS two calendar years ago.

Do you have any unearned income that is more than 10% of your earned income? NoYes

Last year's actual income filed

2 Year's Ago actual income filed

Source

Have you or a business you’ve owned ever filed, or plan to file, for bankruptcy? NoYes

Type PersonalBusiness

Date Filed

Date Discharged

Jamie Fleischner, CLU®, ChFC®, LUTCF

(303) 358-8021
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, Jamie Fleischner, CLU®, ChFC®, LUTCF at (303) 358-8021 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.

Pre-Application Questionnaire

Financial Information