About You

First Name *
Middle Name *
Last Name *
Gender at birth *

Current Age *

Date of Birth (MM-DD-YYYY)*

Month *

Day *

Year *

Height (in Ft. and In.) *

Weight (in Lbs.) *

Tobacco Use Status *

Are you a U.S. Citizen or Legal Immigrant or Permanent Resident or Green Card Holder with SSN? Only US Citizens and Legal Immigrants with SSNs are eligible to apply for Life Insurance in Texas. You can try again once you get an SSN and Legal "Permanent Resident" Status in the U.S.)*
Do you have a Valid Texas State Driver's License or Texas State ID?*

Do you have a U.S. Based Bank or Credit Card Account? (Select what applies)*

Yes, I have a U.S. Based Checking Account
Yes, I have a U.S. Based Savings Account
Yes, I have a U.S. Based Credit Card Account
No, I don't have any of the above. (Sorry, Insurance Companies only accept U.S.-Based Bank Accounts or U.S.-Based Credit Card Accounts as the only forms of payments for Insurance Premiums)

Contact Information

Street Address: *

Apartment, Suite #

City *

State *

ZIP Code *

Mobile Phone Number *

Home Phone Number

Email Address *

Your Beneficiary

Beneficiary First Name *
Beneficiary Middle Name *
Beneficiary Last Name *

Relationship to the Proposed Insured *
If "Other", please specify:

Life Insurance Coverage Quotes Requested

Amount of Coverage *
Your Maximum Budget for Your Monthly Premium *

Health Details

Current Medications that are Prescribed By a Physician (type the name of the medication, or if you are not taking any physician prescribed medications, type "NONE"). Do not include any Over The Counter Medications. *

Any surgery / surgeries in the past 3 years? Please specify (or type NONE or N/A if you have not had any surgeries in the past 3 years)

Have you ever been diagnosed by a Physician to have any of the following conditions? (Select what applies...) *

Heart Attack
Stroke
Cancer
Diabetes

Neuropathy
HBP Lupus
Asthma
COPD

Thyroid Disease
Anxiety / Depression
Kidney Disease
Liver Disease

No, I have never been diagnosed with any of the above medical conditions.

Financial Details

I am ... *

Employed
Self-Employed
Retired
Disabled

What is your Occupation? *

What is your Monthly Income? (Approximate) *

What is your Monthly Mortgage or Rent? (Approximate) *

If you Own Your Home, what is its current value? (Approximate)

How much Home Equity have you built up? (Approximate)

What is your Home Mortgage Term?

Refinanced or Purchased?

Do you pay extra mortgage monthly to pay off the loan early? If yes, how much?

What do you have to offset the cost of Mortgage or Rent for your family when you die? (Select what applies)

401K
IRA

Stocks
Bonds

Mutual Funds
CDs

Significant Savings
None of the above

Validation and Confirmation of Data

Is the proposed insured currently disabled? *
Yes
No

Require the use of a wheelchair? *
Yes No

Does the proposed insured have any chronic illness or condition which requires periodic medical care or may require future surgery? * Yes No

In the past 5 years, has the proposed insured had his or her Driver's License suspended or revoked? * Yes No

Have you ever been convicted of a felony? * Yes No

Currently incarcerated? * Yes No

Please type a confirmation passcode so we can give it to you when we call you up. *

Additional notes or comments that you would like us to know:

Acknowledgements and Consent

Yes, I have reviewed this form thoroughly and I agree that once I click the submit button, I will EXPECT to receive a PHONE CALL from the Assigned Licensed Field Underwriter to confirm the details of what I have provided on this form within 24 to 48 hours.

Yes, I understand that consumers can only get Life Insurance Quotes from Licensed Professionals who are authorized by law to assist in the Consumers' Applications in the State of Texas, who is ALSO bound by Contracts of Agency with many Insurance Companies who ALSO must have permission to represent them as an Independent Contractor, in order to help and assist Consumers in the State of Texas who want to apply for a Life Insurance Policy.

Yes, I understand that the assigned Field Underwriter will be providing their Texas State License Number as an assurance that he / she will perform his/her job to the best of his/her ability and has the authority and responsibility and accountability to give me the information that would best serve me and my family when it comes to Information on my Life Insurance Policy Application.

Yes, I agree to treat them professionally and courteously as they will help assist me in protecting my family with researching for Life Insurance Quotes by using their own Texas Department of Insurance issued License and by using their own Contracts with the different insurance companies to HELP ME in the application process. This is a FREE service that the Licensed Agent or Broker is providing me. I understand that it is the Insurance Company who provides payments to agents directly, and that when I wish to move forward with the Application, it is the Insurance Company who will draft my bank account monthly

Yes, I am aware that Licensed Life Insurance Professionals are NOT telemarketers and are in the life insurance industry in order to help people. At the time of my death, my beneficiaries can't call telemarketers, but they can also call my Life Insurance Agent to help my beneficiaries with the Life Insurance Policy claims, aside from being able to call the Customer Service Department of the Insurance Company.

Yes, I agree with "MyTexasLifeAgent.com's" privacy policy and the terms of use. I acknowledge that there are internet safety measures that this website has put in place to prevent Application Forms abuse. This form was developed using RWD principles also as a deterrent in avoidance of some people from even attempting to commit any type of Insurance Fraud. This specific form collects metadata.

Yes, I am the one requesting for the Life Insurance Quote and will be the Applicant AND the Owner of this policy, should the quotes I receive be affordable and comfortable for my budget.

Yes, I will promptly notify the Field Underwriter whether I WILL PROCEED with the Application, or NOT PROCEED with the Application, so that my file can be closed, in order that no other agent from this organization would waste their time in following up with me in the future. A text message to my Field Underwriter "I WILL NOT PROCEED WITH THE APPLICATION" will suffice for you to note and close my file. That is only fair, and I will do my part too.

Prequalification Questionnaire for an Application for a Life Insurance Policy

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