"Use Zander's online quoting system to search for the most competitive term life insurance plans available. Remember most people with families need 10 times their income in coverage and I recommend 15, 20 or 30 year guaranteed level plans depending on your age. Stay away from Cash Value or Return of Premium plans that waste your money. Zander only deals with top notch insurance companies and has great rates... even for those with pre-existing conditions. Call them at 800.356.4282 with any questions. They are there to help."
- DAVE RAMSEY

Term Life Insurance: Request An Application

At Zander Insurance Group we greatly appreciate your interest in the term life insurance products from the carriers we represent and look forward to working with you. Please be aware that this is not an application. This is a request for an application. You are under no obligation by completing this form and no company will receive any of your personal data or information until you receive, review and sign the specific company application you requested. If you have not received a pricing proposal yet, please visit either our "Instant Quote", or "Send Me Proposal" sections of our website, or call us toll free at (800) 356-4282.

Once you have completed the request form we will transfer your specific detail to the selected company application and return it for your review and signature. Please visit our "Understanding the Application Process" page on this website for more specific details.

Once again, we greatly appreciate your business and look forward to being of futher service.

When you have completed this form, please click the "Send Information" button appearing at the bottom of this form.

Proposed Insurance
YOUR Full Name: *  
YOUR Date of Birth: *  
(Use format: MM/DD/YYYY, i.e. 12/01/1949)
Birthplace: *
City, State and County if applicable
 
Example: Nashville,TN Davidson
Gender:
Marital Status
Social Security Number

 Example: 123-45-6789  

Drivers License Number:

 
Example: 123456789

Driver's License State (2 Letter Abbreviation)
Residence

 

     Address

 

     City:  
     State: (2 Letter Abbreviation)  
     Zip Code:  
Email Address (user@company.com)  
Home Phone Number:  
(999-999-9999, including dashes)
Business Phone Number:
(999-999-9999, including dashes)
Best time during day to reach you:    
(Example:  12:00pm)
Employer's Name:
Employer:
     Address:
     City:
     State: (2 Letter Abbreviation)
     Zip:
Your Occupation
Annual Income Earned
Is the owner/application someone other than the proposed insured?
TERMS OF POLICY REQUESTED
Company Desired:
Amount of Insurance:  
Length of Term  
(Example: 20 years)
Child rider:
Number of units:  
(1 unit is $1,000)
Send Notices To:
If you selected OTHER above, please specify the name of the person who should receive notices about this policy.
Billing Frequency Preference:
Note: If you choose the Monthly option, your monthly premium will be debited automatically from the checking account you specify.

HEALTH INFORMATION FOR
PROPOSED INSURED
Please answer the following questions carefully. This information is very important in helping us get your policy issued as soon as possible.
1. Have the Proposed Insured ever used any form of tobacco? (This includes cigarettes, chewing tobacco, snuff, etc.)

Proposed Insured:
2. If you answered YES to Question Number 1 (above), please indicate the quantity and type of tobacco used by the Proposed Insured:

Examples: # Cigarettes, 20 per day, Yesterday
3. Have the Proposed Insured had any history of drug use or substance abuse?

Proposed Insured:
4. If you answered YES to Question Number 3 (above), please list what was used and date of last use, if you had in-patient or out-patient care, and how long you were in treatment.

Proposed Insured:
5. Height of Proposed Insured:

Example: # 5 ft 6 in

Proposed Insured:    
6. Weight:

Example: # 120 pounds

Proposed Insured:  
7. Any abnormal weight loss or gain in the past 12 months?

Proposed Insured:
8. If you answered YES to Question Number 5 (above), please indicate the number of pounds lost or gained and the reason.

Example: # 20 pounds lost, Flu

BENEFICIARY INFORMATION
Please enter full name, percentage share, and relationship for proposed insured for the beneficiaries of this policy:

Examples:
Primary Beneficiary: Mr. John A. Jones, 50 percent, Father Contingent Beneficiary: Mrs. Elizabeth P. Jones, 50 percent, Mother
Primary Beneficiary:

Contingent Beneficiary


TOTAL LIFE INSURANCE
CURRENTLY IN FORCE
Do you currently have Life Insurance policies in force?
If YES, please provide the following information about your Life Insurance:

Name of Company, Face Amount of Policy, Year of Issue
Example: Aetna, $150,000, 1992
IF YOU HAVE NO POLICIES IN FORCE, PLEASE ENTER "NONE"
Will the policy applied for replace or change any existing life insurance or annuity?
If YES, please provide the following information about the policies/annuities that will be affected:

Name of Company, Face Amount of Policy, Year of Issue

Example: Aetna, $150,000, 1992
IF NO POLICIES WILL BE AFFECTED, PLEASE ENTER "NONE".

GENERAL INFORMATION
Please answer the following questions carefully. This information is very important in helping us get your policy issued as soon as possible.
The following questions apply to the proposed insured. Please give full details to any "YES" questions in the COMMENTS area at the bottom of this section.

In the past five years, have you engaged in flying as a pilot, student pilot, or crew member, or do you intend to become a pilot?


  In the past five years, have you engaged in, or contemplated engaging in: ballooning, parachuting, hang gliding, vehicle racing, scuba diving below 60 feet, mountain climbing, or any other similar sport or avocation?


In the past five years, have you had two or more moving violations, been convicted of reckless driving or driving under the influence of alcohol or drugs, or had your driver's license suspended or revoked?


In the next 2 years do you have any plans to travel or reside outside the United States?

If yes, where will you be traveling?
How long?
For what purpose?

Have you ever had any life or health policy rated, canceled or declined?


Are you currently in the military or national guard?
  If so, what occupation?

Are you currently pregnant?


Are you a US citizen?
  If no, what kind of Visa do you currently have?

Have you ever declared bankruptcy?

If yes, what chapter did you file? 
What was/is the discharge date? 

Enter Premium Quoted By Zander Insurance's Instant Quote:
   
Comments from Above Questions: 


HEALTH STATEMENT
The following questions apply to the proposed insured. Please give full details in the comments area appearing at the bottom of this section.
a. Have any of your immediate family members (parents, brothers, or sisters) been diagnosed with or died from heart disease, cancer, diabetes, or stroke prior to age 60?


If YES, identify family member, disorder, age at death in COMMENTS section.

b. Have you ever had or have you ever been told that you had: high blood pressure, chest pain, stroke, or disease of the heart or blood vessels, cancer or tumor of any kind; epilepsy, mental or nervous disorder; diabetes; lung or respiratory disorder; gastric or intestinal disorder; kidney or urinary tract disorder; disorder of the blood or lympth nodes; or any disease of the reproductive organs?



c. Are you currently taking or have you been advised to take any medication?

Comments from Above Questions:
Example:
  • I am taking ProCardia 20 MG/DAY.
  • I have diabetes.