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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