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Accurate Record Keeping

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Find Out if You Qualify to Sell Your Policy

Please complete the form below to take the next step toward selling your policy.

"*" indicates required fields

Step 1 of 7 - User Information

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Your Name*

First Last

Phone Number*

Email Address*

Policy Death Benefit*

Please enter a number greater than or equal to 10000.

Insured's Age *

Please enter a number from 18 to 130.

Insured's Date of Birth*

MM slash DD slash YYYY

Use Insured’s Age Instead of DOB

Insured's Health Status*

Insured's Gender*

Are you the insured?*

Yes, I am the insured

No, I am not the insured

Terms & Conditions Agreement*

I agree to the terms & conditions and privacy policy.

Insured Contact Information

In the previous step, you indicated that you are not the insured on the policy. Please provide the insured's contact information.

Insured Name*

First Last

Insured Phone*

Insured Email*

What is your relationship to the insured?*

Policy Information

We need to evaluate your policy information. Please provide accurate answers or respond "I don't know" if you are unsure.

What is the policy type?*

How long has the policyowner owned the policy?*

Did you receive the policy from a current or former employer?*

Yes

No

Insured's Health History

Providing an accurate health history is important in determining eligibility.

Has the insured ever been diagnosed with any of the following? Select all that apply.

ALS (Lou Gehrig's Disease)

Alzheimer's Disease or Dementia

Cancer

Chronic Lung or Respiratory Disease (other than Asthma)

Heart Disease (Including Pulse or Rhythm Issues)

Insulin Dependent Diabetes

Kidney or Renal Disease

Liver Disease

Multiple Sclerosis (MS)

Parkinson's Disease

Stroke / Cerebrovascular Disease

Does the insured use any assistive devices or ongoing medical support such as homecare hospice or continuous therapy?

Yes

No

Please explain assistive devices / medical support

Please provide any additional health information for the insured that you would like us to consider.

Additional People Insured on the Policy

Some policies insure multiple people, often a spouse or significant other. If the policy insures more than one person, please provide their information.

Is there another insured person on the policy who is still living?*

Yes

No

Second insured's Name*

First Last

Second insured's Health Status*

Second insured Age *

Please enter a number from 18 to 130.

Second insured's Date of Birth*

Month

Day

Year

Use Insured’s Age Instead of DOB

Additional Policies

Some people maintain more than one life insurance policy. Evaluating all of your policies at once may improve the insured's ability to qualify.

Do you have any additional life insurance policies?*

Yes

No

What is the total death benefit of the additional policy or policies?*

Please enter a number greater than or equal to 10000.

How did you hear about Clarity Wealth?*

TV Options

Please select the TV channel or program

Radio Options

Please select the Radio channel or program

Internet / Social Media Options

Please select an Internet / Social Media option

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