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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