Take This 60-Second Survey To See If You Qualify
Get pre-approved in 60-seconds by answering a few simple questions
First Name
*
Last Name
*
What is your date of birth?
*
What is your cellphone number?
*
What is your city of residence?
*
What is your state of residence?
*
What is your zip code?
*
Email
*
I agree to
terms & conditions
provided by the company. By providing my phone number, I agree to receive text messages from the business.
How much do you weigh?
*
What is your height (in inches)?
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Do you have a spouse or domestic partner?
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Yes
No
Do you have any dependent children?
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Yes.
No.
If you died unexpectedly tomorrow, what debts would you not want your beneficiary to worry about? (choose as many as you want)
*
Mortgage
Student Loans
Auto Loans
Credit Cards
Misc.
N/A
What is the estimated total amount from the previous question?
*
$
How much money, if any, do you want to leave to cover future educational expenses?
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$
How long do you want to be covered with life insurance?
*
Less than 10-years
10 to 30-years
More than 30-years
Do you have life insurance through your employer?
*
Yes. I do.
No. I do not.
Do you currently have a life insurance policy outside of what your employer provides?
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Yes. But I do not think it is enough.
Yes. But I am open to a better program.
No. I need coverage right away.
Have you ever had a felony?
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Yes.
No.
Within the past 5-years, have you been advised to receive treatment or counseling to discontinue the use of alcohol?
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Yes.
No.
Within the past 5-years, have you used any controlled substances except as prescribed by a physician? (check all that applies)
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Marijuana
Heroin
Cocaine
Other
N/A
Within the past 2-years, have you been advised to have any of the following: EKG, CT scan, bone scan, biopsy, colonoscopy?
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Yes.
No.
Within the past 2-years, have you engaged in extreme recreational activities (e.g. motor/vehicle racing, mountain/rock climbing, scuba/sky diving, etc.)?
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Yes.
No.
Do you use any forms of tobacco? (check all that applies)
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Cigarettes
Vape
Chew / Snuff / Dip
N/A
Have you been diagnosed with sleep apnea, seizures, or epilepsy?
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Yes.
No.
Are you currently taking prescription medicine?
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Yes.
No.
Have you been diagnosed with cancer (other than skin)?
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Yes
No
Do you use oxygen equipment (not including CPAP machine)?
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Yes.
No.
Have you been diagnosed with any of the following: diabetes, high blood pressure, stroke, congestive heart failure, or heart attack?
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Yes.
No.
Have you been diagnosed with any of the following: Dementia, Alzheimer's, MS, ALS, or muscular dystrophy?
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Yes.
No.
Have you ever been denied life insurance?
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Yes.
No.
What is your annual income?
*
$
What is your monthly budget to begin your life insurance coverage?
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$
Who, from WILGEN Group & Associates sent you this survey? (if unsure, type Unknown)
*
Other than life insurance, what other areas, if any, would you like more information? (choose as many as necessary)
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Investments
Taxes
Legal Shield
Debt Medic
Trust Fund
N/A
Privacy
/
Terms