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Please select the quote type you are requesting:

Multiple Choice

Personal / Family Life Insurance
Group Life Insurance
Key Man Life Insurance

Please choose the number of individuals this quote request is for:

Name (Full Name)

Telephone - Home

Telephone2 Mobile

Email Address *

Home Address

Address Line 1

City

State

Home Address

Address Line 1

City

State

Zip Code

Age: Date of Birth

Details of Life Insurance Requested (What you are looking for in Life Insurance Policy):

Type of Life Insurance Desired?

Amount of Insurance Requested - (Main Insured person)

Notes

Riders Available (Riders are add Do you want any of the following riders?on features to an insurance policy) Do you want any of the following riders?

Child Rider
Accidental Death Benefit Rider
Inflation Rider
Return of Premium
Disability Rider
Cost of Living Rider
Long Term Care Benefits

Section Divider

Details of your Current Life Insurance policy / policies. (We are required to list all existing life insurance policies.)

Do you currently have Life Insurance?

Personal / Family Details

Are you Married?

Premium Payments

Is all or a portion of the initial or future premiums for the proposed policy being paid,directly or indirectly,by anyone other than the Owner and/or the Proposed Insured?

Yes
No

Are you borrowing in order to pay all,or a portion,of the initial or future premiums,entity other than the Owner or the Proposed Insured ?

Has any Proposed Insured or Owner

Ever sold a policy or been involved in any discussions about the possible sale or assignments of the policy applied for a life or viatical settlement company or to another third party?

Does any proposed Insured or Owner

Presently intend to assign or sell the life insurance policy applied for to a life or Viatical settlement company or to another third party ?

Has any of the Proposed insured recently applied

Ever applied for insurance or Policy reinstatement which was declined postponed,rated,Rider or modified ?

Start of Medical / Health Information

Name

Weight

Have you Gained or Lost more than 10 Pounds in the past 12 months

List of Health Conditions?

Do you have or have had any of the following health conditions? If you have had something that is not on this list, please put into the comments section

Diabetes
Mental Health Issues
HIV
M.S. (Multiple Sclerosis)
High Blood Pressure
Sleep Apnea
Shortness of breath or Chronic Cough
Other
Heart disease
Alcohol,Drug us
Lupus
Multiple Distrophy
High Cholesterol
Organ Transplant patients
Emphysema
Cancer
Strokes or TIA's
DUI
Chrones Disease
Weight
Asthma
COPD

Tobacco Use

Do You Smoke?

Within the last five years smoked Cigarette if yes indicate the name of the proposed insured and date last smoked.

Within the last five years used other forms of Tobacco such as cigars,pipe,chewing Tobacco or Smuff if yes indicate the name of the proposed insured and date last used.

If you have a medical / health condition, please type in what it is, when diagnosed and if it is under control & how long has it been under control or not under control.

Are you currently under a doctors watch for any medical condition

Hospitalization

Have you been hospitalized for longer than 1 day

If Yes (Hospitalized for 1 day or longer, What For & When)

List of Medications

Are you currently taking any medications prescribed by a doctor?

If you take any medications, list the names of medications & dosage & frequency.

Please comment on any medical conditions you have or have had.

Doctors Info (For the purpose of requesting medical records)

Doctors Name

Doctors Tel #

Doctors Fax #

Doctors Address

Do you have a specialist doctor?

Hazard Activities

Do you plan on Travelling outside of the U.S. in the next 2 years ?

Yes
No

Have you had any of the following items in the past 3 years.

Do you plan on Travelling outside of the U.S. in the next 2 years ? (copy)

DUI
Suspended or revoked License
Any type of Moving Traffic violations

Do you actively participate in any of the following activities or Do you plan on doing any of the following activities in the next 5 years..

Sky-Diving or Hang Gliding
Race Car Driving
Speed Boat Racing
Down Hill Snow Ski Racing
Scuba Diving
Rock Climbing

Non-Resident (Need a Visa)

Are you a Non-Resident (Need a visa) to be in the U.S.?

Yes
No

Note: Make the space not so big between Non-Resident (Need a Visa) & the line with the check box & Are you a Non-Resident (Need a visa) to be in the U.S.?

Do you or have you used Illicit Drugs in the past 5 years

Family Medical History

Have you had a parent or Sibling diagnosed or die from any of the following prior to age 65 ?

Heart Disease
Cancer
Stroke
Other Medical Problems

Do you fly airplanes or are a part of a crew on small engine aircraft?

Occupation

Recent Life Insurance Applications or denials

Have you applied for life insurance recently?

Have you been denied or turned down for life insurance with any other insurance company?

Within last five years been fined more then $100 for any moving (Traffic) Violation ?

Within the last five years been charged with but not acquired of the violation of any criminal law other than minor moving (traffic) Violation ?

Been placed on current active status in the armed forces or except to have active status in the near future . "(If yes, an additional form will need to be completed)"

Filled for Bankruptcy within the last five years if yes indicate type and date of discharge.

Additional Comments:

Income (Personal & all - Gross Income)

Annual Income - Applicant

Annual Income (Spouse - if applicable)

Assets (Details & Value of Assets) This helps us know how much in Assets to calculate for your net worth

Home Value

Real Estate Assets

Bank / CD's / Securities

Retirement account Assets (Value)

Auto's, RV's, Boat's, similar items - Value

Jewelry / Artwork Value

Other Assets

Total Assets

Amount of Debt

Real Estate Debt (Mortgage Loans)

Student Loans

Secured Debt (Auto Loans, other secured Debt)

Unsecured Debt

Business Debt (Loans)

Other Debt

Total Debt

Policy Beneficiary

Beneficiary #1

Name of Person or Entity

Relationship

Percentage (%)

Beneficiary (receive $ when you die).

Beneficiary

Contingent Beneficiaries

Contingent Beneficiary #1

Name

Relationship

Percentage (%)

Beneficiary (receive $ when you die).

Advanced Estate planning questions ( Beneficiary Designation )

Beneficiary Designation options

Notes:

Per Capita (click for an explanation & examples)

Per Stirpes (click for an explanation & examples)

Payment Options for beneficiaries

Lump sum payment
Life time annuity payment
Annuity payment over a certain period of time

Additional notes for Payment Options for beneficiaries:

You also have the ability to specify before you die how certain recipients will receive their funds if you choose to specify this in your planning.

A few of the options include:

(copy)

1) Lump sum payment Paid in one lump sum at death of the insured
2) Life time annuity payment Life Insurance is to be paid over the beneficiaries life based on the age of the beneficiary.
3)Annuity payment over a certain period of time. Payments are to be spread out over a fixed period of time, ie. 5 years, 10 years, 15 years, 20 years or any period of time in-between.

Other services: I'm Interested in the following:

Would you be interested in a Funeral Plan Insurance Pre-Needs)? Lock in funeral rates at todays rate.

Would you like to convert your 401-K or Roth IRA to a guaranteed no loss of funds annuity?

Would you like a higher Return than a bank CD w/ No Loss of principle?

Are you interested in refinancing your mortgage?

How did you hear about us?

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- Estate Planning

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About
Contact Us
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Product Offered
Articles
- Estate Planning

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About
Contact Us
- Refer To Friend
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Product Offered
Articles
- Estate Planning