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Life Insurance Quote Request Form
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Agent Information
Agent Name
*
Work Phone
*
Fax
Preferred Contact Person
Email
*
Date of Appointment
Signing State
*
Select signing state
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Client Information
Is this a survivorship case?
*
Yes
No
Basic Information - First Insured
First Insured's First Name
*
First Insured's Last Name
*
Gender
*
Select gender
Male
Female
Date of Birth
*
Age
Build & Vitals - First Insured (if known)
Height
Select Height
4' 10"
4' 11"
5' 0"
5' 1"
5' 2"
5' 3"
5' 4"
5' 5"
5' 6"
5' 7"
5' 8"
5' 9"
5' 10"
5' 11"
6' 0"
6' 1"
6' 2"
6' 3"
6' 4"
6' 5"
6' 6"
6' 7"
6' 8"
Weight
Cholesterol
Blood Pressure
Estimated Underwriting Class
*
Select underwriting class
Preferred Plus
Preferred
Standard Plus
Standard
Smoker
Type Table A
Type Table B
Type Table C
Type Table D
Type Table E
Type Table F
Type Table G
Type Table H
Type Table U
Tobacco Use - First Insured
Has the first insured used any form of tobacco in the past five years? (including cigarettes, pipes, cigars, nicorette gum, vapor, etc.)
*
Yes
No
What form?
When was the last time the first insured used any form of tobacco?
Driving Record - First Insured
How many moving violations has the first insured had within the last 3 years?
0
1
2
3
More than 3
Has the first insured ever been convicted of a DUI or reckless driving charge?
Yes
No
Medical Impairments & Family History - First Insured
Are there any occurrences of heart disease, cancer or diabetes for the first insured or their immediate family?
Yes
No
List any know medical impairments, such as diabetes, cancer, hypertension, etc:
Is the first insured currently taking any medications?
Yes
No
Is there any additional medical information we need to advocate for the insured?
Basic Information - Second Insured
Second Insured's First Name
*
Second Insured's Last Name
*
Gender
*
Select gender
Male
Female
Date of Birth
*
Age
Build & Vitals - Second Insured (if known)
Height
Select Height
4' 10"
4' 11"
5' 0"
5' 1"
5' 2"
5' 3"
5' 4"
5' 5"
5' 6"
5' 7"
5' 8"
5' 9"
5' 10"
5' 11"
6' 0"
6' 1"
6' 2"
6' 3"
6' 4"
6' 5"
6' 6"
6' 7"
6' 8"
Weight
Cholesterol
Blood Pressure
Estimated Underwriting Class
*
Select underwriting class
Preferred Plus
Preferred
Standard Plus
Standard
Smoker
Type Table A
Type Table B
Type Table C
Type Table D
Type Table E
Type Table F
Type Table G
Type Table H
Type Table U
Tobacco Use - Second Insured
Has the second insured used any form of tobacco in the past five years? (including cigars, pipes, cigars, cigarettes, nicorette gum, vapor, etc.)
*
Yes
No
What form?
When was the last time the second insured used any form of tobacco?
Driving Record - Second Insured
How many moving violations has the second insured had within the last 3 years?
0
1
2
3
More than 3
Has the second insured ever been convicted of a DUI or reckless driving charge?
Yes
No
Medical Impairments & Family History - Second Insured
Are there any occurrences of heart disease, cancer or diabetes for the second insured or their immediate family?
Yes
No
List any know medical impairments, such as diabetes, cancer, hypertension, etc:
Is the first insured currently taking any medications?
Yes
No
Is there any additional medical information we need to advocate for the insured?
Quote General Information
What is the objective of the case?
Do you have a specific carrier(s) in mind?
What is the client's premium expectation?
Illustration Information
Policy Type
*
Select Type
Term Life - ART
Term Life - 10 Year
Term Life - 15 Year
Term Life - 20 Year
Term Life - 30 Year
Term Life - ROP
Universal Life
Indexed Universal Life
Variable Universal Life
Guaranteed Universal Life
Whole Life
Survivorship Universal Life
Face Amount
Select Face Amount
$100,000
$250,000
$500,000
$750,000
$1,000,000
Other Amount
Mode of Premium
*
Select Mode
Annually
Semi-Annually
Quarterly
Monthly (PAC)
Solve For
Select solve for
No Lapse Guarantee
Endowment
Cash Value At Age
Face Amount
Premium Payment Period
*
Select payment period
Lifetime Pay
Single Premium
Pay 5 Years
Pay 10 Years
Pay 15 Years
Pay 20 Years
Pay to Age 65
Pay to Age 100
Other
Specified Premium
Additional 1st Year Premium
*
Is the premium from a 1035 Rollover?
Yes
No
Will there be any withdrawals or loans demonstrated in this quote?
*
Yes
No
Please describe.
Will there be any riders on this policy?
*
Yes
No
Please select all that apply.
LTC Rider
Chronic Care Rider
Spousal Term Rider
Child Term Rider
Disability Waiver of Premium Rider
Additional Notes
Additional Quote Information
Do you need any additional resources with your quote?
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