Life Quote

    Fields labeled with an * are REQUIRED

    Agent Information *

    Agent Name *

    Agent Email *

    Agent Phone *

    Fill out the form below as completely as possible.

    We will prepare your quote, based on the information you provide.

    CLICK HERE to download a Fact Finder form to help you gather important information.

    CLICK HERE to download a Generic Underwriting Reference, to quickly help you determine rate class.

    If you experience any problems, please contact us at (888) 539-1633. All personal information is protected by HIPAA regulations.

    Plan of Insurance Requested *

    Purpose for Coverage: *

    Full Underwriting or Simplified Issue? *

    Coverage Type: *

    Term

    Survivorship:

    Rate Class *

    Rated Level (if applicable)

    Coverage Amount *

    Client budget per month for this plan $:


    Client Information *

    Full Name *

    Phone *

    Email *

    State *

    Gender *

    Date of Birth *

    Age *

    Nicotine Use *

    Current Nicotine Use *

    Describe if "Other"

    Quantity per month

    Former tobacco use: (List each type of tobacco, quantity and frequency used, and date of last use)

    Build *

    Height *

     
    ft.

     

     
    in.

    Weight *

     
    lb.

    Family History *

    Family history is a consideration for each rate class

    To your knowledge, is there any family history (parent or siblings) with onset of disease prior to age 60 due to:

    • Cardiovascular disease

    • Cerebrovascular disease

    • Diabetes

    • Cancer

    Please answer YES or NO. *

    If YES, please provide full details with impairment, age at onset and age at death if deceased:

    Father:

    Mother:

    Siblings:

    Blood Pressure/Cholesterol

    Latest BP reading:

    Latest total cholesterol (mg):

    Latest cholesterol/HDL ratio:

    Are you taking medication for blood pressure?....

    Name of medication

    Are you taking medication to lower cholesterol?...

    Name of medication

    Aviation/Avocation *

    NoneFlyingRacingSky DivingScuba DivingOther (describe below)

    Description:

    Citizenship/Residency/Travel *

    US Citizen? *

    If no, provide type and expiration date of visa, green card status, and length of time in the USA:

    Any future plans to live or travel outside the USA?

    If yes, provide purpose, cities, countries, frequency, and duration:

    Driving History

    Have you had any of these motor-vehicle-related incidents in the past 10 years?

    Provide dates & details:

    Medical History *

    Have you ever had, been told you had, or been treated for any of the conditions listed?
    If yes, check the box and explain each:

     

    Alcohol Abuse

    Alzheimer's/dementia/cognitive impairment

    Asthma

    Cancer

    Cirrhosis

    COPD

    Coronary artery or cerebrovascular disease

    Crohn's Disease

    Depression/anxiety

    Diabetes

    Drug Abuse

    Epilepsy

    Heart Murmur/Valve Disease

    Hepatitis

    Irregular Heartbeat/Palpitations

    Kidney Disease

    Lupus

    Multiple Sclerosis

    Peripheral Vascular Disease

    Rheumatoid Arthritis

    Sleep Apnea

    Stroke

    Other

    List dates, diagnosis, details & treatments. Also enter names, addresses, and phone numbers of all consulted physicians.

    (refer to Common Medical and Non-Medical Impairment for critical underwriting factors):

     

    Please verify that all the information you have entered is correct, then click Submit

     

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