Quote Request
Please complete this form and hit "submit". Questions with a * are required. Your information will remain confidential.
1. Full Name: *
2. Name of Person to Insure if Different:
3. E-Mail Address: *
4. Street Address: *
5. City: *
6. State & Zip Code: *
7. Home Phone: *
8. Alternate Phone:
9. Best Time to Reach You: *
  • Mornings
  • Afternoons
  • Evenings
  • Weekends
  • No Preference
10. Sex: *
  • Male
  • Female
11. Date of Birth: *
12. Age you are today:
13. Height
14. Weight:
15. Tobacco Use: *
  • No
  • Yes
16. Basic Health - Are you now or have you ever been treated for any of the following (Check all that apply): *
  • AIDS/HIV
  • ALS
  • Alzeimer's
  • Aneurysm
  • Blood Disease
  • Cerebral Palsy
  • Cystic Fibrosis
  • Cancer (Any type)
  • Diabetes
  • Epilepsy
  • Heart Disease
  • High Blood Pressure
  • Kidney Disease
  • Liver Disease
  • Lung Disease
  • Lupus
  • Mental Disorders
  • Multiple Sclerosis
  • Organ Transplant
  • Parkinson's Disease
  • Pulmonary Embolism
  • Seisures
  • Stroke
  • Tuberculosis (TB)
  • None of the Above
17. Are you currently taking prescription medications? *
  • Yes
  • No
18. If yes, list medications here:
19. Type of Insurance Requested: *
20. Appoximate Amount of Insurance Desired: *
21. Annuity Premium (If Applicable)
22. Are you wanting to insure yourself or somebody else? *
  • Myself
  • Spouse
  • Child
  • Grandparent
  • Other Relative
  • Business Associate
  • Other
23. Do you currently have Life Insurance? *
  • Yes
  • No
24. Is the policy you are looking for intended to replace any other life insurance policy? *
  • Yes
  • No
25. Have you requested and received other quotes?
  • Yes
  • No
26. Have you ever been turned down for a life insurance policy?
  • Yes
  • No
27. Additional comments or questions:
 

Term Insurance covers you for a term of one or more years. It pays a death benefit only if you die in that term. Term insurance generally offers the largest insurance protection for your premium dollar. It generally does not build up cash value, but there are Term policies that offer Return of Premium riders that will refund your premiums if you out live the term.

You can renew most term insurance policies for one or more terms even if your health has changed. Each time your renew the policy for a new term, premiums may be higher. Ask what the premiums will be if you continue to renew the policy. Also ask if you will lose the right to renew the policy at some age. For a higher premium, some companies will give you the right to keep the policy in force for a guaranteed period at the same price each year. At the end of that time you may need to pass a physical examination to continue coverage, and premiums may increase.

You may be able to trade many term policies for a cash value policy during a conversion period­, even if you are not in good health. Premiums for the new policy will be higher than you have been paying for term insurance.

 


This web site may contain concepts that have legal, accounting and tax implications. It is not intended to provide legal, accounting or tax advice. You may wish to consult a competent attorney, tax advisor, or accountant.
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