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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.
Purpose for Coverage:
Full Underwriting or Simplified Issue?
Full UnderwritingSimplified Issue
—Please choose an option—TermAnnual Renewable TermULVULIULWLSingle Premium WL
—Please choose an option—10 Year15 Year20 Year25 Year30 Year
—Please choose an option—SULSVULSWL
—Please choose an option—Best RatePreferredStandardRatedNot Sure
Rated Level (if applicable)
Client budget per month for this plan $:
—Please choose an option—AKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVIVAWAWVWIWY
—Please choose an option—FemaleMale
Date of Birth
Current Nicotine Use
—Please choose an option—NoneCigarettesCigarsPipeDipChewNicotine GumECigOther
Describe if "Other"
Quantity per month
Former tobacco use: (List each type of tobacco, quantity and frequency used, and date of last use)
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:
Please answer YES or NO.
—Please choose an option—YesNo
If YES, please provide full details with impairment, age at onset and age at death if deceased:
Latest BP reading:
Latest total cholesterol (mg):
Latest cholesterol/HDL ratio:
Are you taking medication for blood pressure?....—Please choose an option—YESNO
Name of medication
Are you taking medication to lower cholesterol?...—Please choose an option—YESNO
NoneFlyingRacingSky DivingScuba DivingOther (describe below)
—Please choose an option—YESNO
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:
Have you had any of these motor-vehicle-related incidents in the past 10 years?
—Please choose an option—NoneMoving ViolationReckless DrivingDWI or DUILicense SuspensionLicense Revoked
Provide dates & details:
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:
Coronary artery or cerebrovascular disease
Heart Murmur/Valve Disease
Peripheral Vascular Disease
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
AGREEMENT: By clicking and submitting this form with my name, phone number, and e-mail address, I agree that I am at least 18 years of age. I agree that I am the current authorized user of the phone number and e-mail address submitted. I expressly consent to opt in to receive e-mails and text messages from Empower Brokerage about health insurance, life insurance, Medicare Supplements, Medicare services and other options. Empower Brokerage is an independent insurance agency and is not affiliated with the federal Medicare program. By clicking and submitting this form, I understand that I am enrolling in an ongoing marketing campaign by Empower Brokerage, and I will receive text messages and e-mails as part of the ongoing Empower Brokerage marketing campaign. By clicking and submitting this form, I am authorizing Empower Brokerage to provide my information to a licensed agent, and I am authorizing the agent to contact me. I am also authorizing the agent to call, e-mail, or text me at the phone number and email address I provided (even if that phone number is on any Do Not Call Registry or is a mobile number). I am consenting to calls with Empower Brokerage being recorded and monitored.
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