Fairlie Insurance Inc.

Supplemental Health Questionnaire

• Full Document [PDF - 840 kb]
• Page 1 of 3 [PDF - 188 kb]
• Page 2 of 3 [PDF - 353 kb]
• Page 3 of 3 [PDF - 297 kb]

Manual Application

• Sample [PDF - 1.23 MB]
• Blank Application [PDF - 2.08 MB]
• contact us for the password

Change Request

• Change Request Form [PDF - 2.73 MB]
• Non-Smokers Declaration Form [PDF - 771 kb]

Transamerica Life Application Forms

• Joint Transamerica Life Application [PDF - 312 kb]
• Fillable short form Transamerica Life application [PDF - 704 kb]

Life Insurance Disclosure

• Life Insurance Disclosure Form [PDF - 112 MB]

Contact Request

• Contact Request Form [PDF - 2.8 kb]

Is this a single or joint policy? Single Joint

Loan Amount : $

Monthly Loan Payment Amount : $

Rate Calculator	Applicant One	Applicant Two
Age:	18-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-64	18-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-64
Do you smoke?:	Yes No	Yes No
Choice for Elimination period:	60 Day 90 Day

* No insurance will come into effect, this is an illustration only.
* These are the most current rates, but rates are subject to change.

For details call Fairlie Insurance
1-800-668-9557

Worksheet for Blended Premiums Group Mortgage Insurance

For immediate service call
Fairlie Insurance Agent

1-800-668-9557
Or use our contact form