The purpose of this form is simply to gather information to help complete an application for
disability or life insurance - it is not an application. If you apply for insurance you may be asked
additional or different questions. Once you have completed this form, your agent will use the
information requested in this pre-application questionnaire to help prepare your formal
e-Application, which requires your review and authorization before being submitted to
the insurance company, a separate secure link will be sent to you when this process is complete.
Your agent may contact you with questions.
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, Jack Evans at (860) 857-4770 with any questions. Thank you for working
with us on your coverage.
Certified Financial Services 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