Prequalification Rate Class
Rate Class Qualification

Bearcat Brant
CEO/National Independent Agent
National Producer Number: 17995375

Direct: (650) 275-5030
Fax: (650) 651-1556

Email: bc@brantinsurance.com
Website: www.brantinsurance.com

1) Fill out the questionnaire to isolate an accurate rating class (or speak to us on the phone).
2) Be matched with the best carrier and product based on your unique profile.
3) APPLY via email or over the phone with me.
4) Get approved and pick your due date (Voice signature/Docusign).

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Email *
Full Legal Name *
Phone Number *
Full Address
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Coverage Amount
Beneficiary Information
Do you have any existing annuity or life insurance or have any application pending for such coverage with this Company or any other company? *
What is your height and weight?
Have you used any tobacco, nicotine or e-cigarette products in the last 12 months?
Clear selection
Have you ever been diagnosed or received treatment for Lung Disease? COPD, Emphysema
Clear selection
Do you require the use of bottled oxygen (excluding CPAP machin)?
Clear selection
Have you ever been diagnosed or received treatment for diabetes?
Clear selection
Have you been diagnosed or treated for Cancer within the last 24 months?
Clear selection
Have you ever had any kidney insufficiency? Dialysis? Cirrhosis? Hepatitis?
Clear selection
Within the last 24 months, have you had a Heart Attack, Bypass Surgery, Stent Surgery, Angina, Pacemaker, Defibrillator, Stroke, Seizure, Aneurism?
Clear selection
Congestive Heart Failure?
Clear selection
Lupus? Multiple Sclerosis? Parkinson’s? Lou Gehrig’s?
Clear selection
Have you ever been diagnosed or received treatment for Alzheimer’s or Dementia?
Clear selection
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