Mortgage Protection Application - Your Own Bank

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Get protection for your family

Gender

Male Female

Date of birth

Next, household & general information

Do you have a spouse or partner?

Yes No

Smoker?

Yes No

Height

Weight

Spouse/Other Name

Date of Birth

Age

Height

Weight

Smoker?

Yes No

Medical Concerns

Do you have any medical concerns?

Yes No

Partner medical concerns?

Yes No

High Blood Pressure

Yes No

Heart Attack

Yes No

Stroke

Yes No

Cancer

Yes No

Diabetes

Yes No

High Cholesterol

Yes No

DUI/Substance Abuse

Yes No

Any Surgeries

Yes No

Any Diseases

Yes No

Accidents

Yes No

Notes

High Blood Pressure

Yes No

Heart Attack

Yes No

Stroke

Yes No

Cancer

Yes No

Diabetes

Yes No

High Cholesterol

Yes No

DUI/Substance Abuse

Yes No

Any Surgeries

Yes No

Any Diseases

Yes No

Accidents

Yes No

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Medications

Are you taking medications?

Yes No

Is the partner taking medications?

Yes No

Applicant Meds List

Partner Meds List

Mortgage Information

Loan Amount

Lender

Mortgage Term

Monthly Payment

Miscellaneous

Occupation

Occupation (partner)

Availability

Availability (partner)

Beneficiary Full Name & Relationship

Do you have children?

Yes No

Children Age

Children Age

Children Age

Contact information

Phone Number

Email

Terms of Service

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