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:
 

Whole Life Insurance covers you for as long as you live if your premiums are paid. You generally pay the same amount in premiums for as long as you live. When you first take out the policy, premiums can be several times higher than you would pay initially for the same amount of term insurance. But they are smaller than the premiums you would eventually pay if you were to keep renewing a term policy in your later years.

Some whole life policies let you pay premiums for a shorter period such as 20 years, or until age 65. Premiums for these policies are higher since the premium payments are made during a shorter period.
 

Universal Life Insurance is a kind of flexible policy that lets you vary your premium payments. You can also adjust the face amount of your coverage. Increases may require proof that you qualify for the new death benefit. The premiums you pay (less expense charges) go into a policy account that earns interest. Charges are deducted from the account. If your yearly premium payment plus the interest your account earns is less than the charges, your account value will become lower. If it keeps dropping, eventually your coverage will end. To prevent that, you may need to start making premium payments, or increase your premium payments, or lower your death benefits. Even if there is enough in your account to pay the premiums, continuing to pay premiums yourself means that you build up more cash value.

View CNBC Video: The Value of Permanent Life Insurance (4 min.)

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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