EApps

Additional Information

Marital Status

Primary Beneficiary

Optional for disability-only applications. Beneficiary details are required on the formal Guardian application, so completing them here saves a follow-up later.

Full Name

Date of Birth:

Relationship to Proposed Insured

Gender

Percentage %

Social Security Number

Phone Number

Is Address same as Owner NoYes

Per Stirpes NoYes

Mailing Address

City

State

Zip

Contingent Beneficiary

Full Name

Date of Birth:

Type

Relationship to Proposed Insured

Gender

Percentage %

Social Security Number

Phone Number

Is Address same as Owner NoYes

Per Stirpes NoYes

Mailing Address

City

State

Zip

Do you plan to reside or travel outside of the U.S.? NoYes

City and Country (where do you plan to travel?)

Departure date

Return date

Within the past five years, have you been charged with or convicted of any motor vehicle violations or had your driver's license suspended or revoked? NoYes

Please provide details of the violation and/or penalty

Driver's License Number

Driver's License State

In the past 10 years, have you ever pled guilty to, pled no contest to, or been convicted of a felony or misdemeanor? NoYes

Please provide details

Within the last three years, have you participated, or do you plan to participate in piloting any type of aircraft or hang gliding? NoYes

Please provide details

Within the last three years, have you participated, or do you plan to participate in mountain or rock climbing, scuba diving, contact martial arts, motor vehicle racing, parachuting or skydiving or other hazardous activities? NoYes

Please provide details

Have you used tobacco, nicotine, or any nicotine delivery system in any form in the last 12 months? NoYes

Please provide details

Did you quit? NoYes

When did you quit?

Are you a member of the armed forces (including the Reserves) or have you entered into a written agreement to enter the military services? NoYes

Do any of the following apply?

Your professional or occupational license or certification has ever been suspended, revoked, restricted, inactivated, surrendered, or the like.
There is a pending investigation or complaint concerning you with a regulatory, governmental, or other entity that oversees your profession.
You have been disbarred; or
You have ever been fined or sanctioned by an entity that oversees your profession.

NoYes

Please provide details

Mark Swenson

(510) 789-2395
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, Mark Swenson at (510) 789-2395 with any questions. Thank you for working with us on your coverage.

Pacific Advisors, LLC 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

Additional Information

Primary Beneficiary

Contingent Beneficiary