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Life Insurance Buyback
Individual Benefits, Inc. adheres to a strict confidentiality code. During the information gathering stage, only health and insurance professionals are contacted with your notarized information release forms. By submitting this information electronically via this secure form, I (the applicant) do warrant and swear that all the information contained in this application to Individual Benefits, Inc. is true and correct to the best of my knowledge.

Legal Name:
Mailing Address:
City:
State:
Zip:
E-mail Address:
Daytime Phone Number:

Evening Phone Number:
Best Time To Call:
Birthdate:
Name of Insurance Company:
Face Amount of Policy: $
Is this an Individual or employer provided policy?:
Have you been diagnosed as having a terminal illness?:
If yes, when?:
Please provide a brief description of your medical condition:
Please let us know any special requests or comments regarding confidentiality code.:
 



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