Quote Request: Term Life, Disability

For the most accurate quote possible, please complete all fields. We keep all data strictly confidential - please see our Privacy Policy. Please do not hit "Enter" or click "Send Quote Request" until the form has been completed. For serious health problems or unusual circumstances, please call (toll free) 877-254-4429 for a no-cost, confidential consultation. *Red = Required Field.

Advisor Information

Financial Advisor Name *

Financial Advisor Company

Proposed Insured

First Name *

Middle Name

Last Name *

Preferred Name / Nickname

Date of Birth (MM/DD/YYYY) *

Are you a U.S. Citizen? *

Yes No Unknown Unanswered

Immigration Status *

Permanent Resident/Green Card Holder Visa Holder

Country of Birth *

Date of Entry *

Visa/Green Card Type *

Visa/Green Card Expiration Date *

Contact Information

Preferred Contact Number *

Email Address *

Current Address

Address

Address 2 (Apt, Suite, etc...)

City *

Zip Code

Household Information

Marital Status *

Number of Children *

Ages of Children

Occupation

Are you currently employed? *

Yes No Unknown Unanswered

Occupation *

Annual Earned Income ($) *

Please select: *

Stay at home parent Retired Other

Please explain *

Term Coverage

Amount of Insurance ($) *

Guaranteed Term Years *

10 15 20 25 30 35 40

Will this replace any existing insurance? *

Yes No

Premium Mode *

Annual Monthly Bank Draft Other Method

Do you need additional coverage options? *

Yes No

Amount of Insurance ($) *

Guaranteed Term Years *

10 15 20 25 30 35 40

Amount of Insurance ($)

Guaranteed Term Years

10 15 20 25 30 35 40

Amount of Insurance ($)

Guaranteed Term Years

10 15 20 25 30 35 40

Have you applied for life, LTC, disability or health insurance within the last year? *

Yes No Unknown Unanswered

Please specify the company, type and amount of insurance: *

Status of the application *

Pending Approved Issued Declined

Reason for declined application:

Have you ever been declined life, disability or LTC coverage? *

Yes No Unknown Unanswered

Please explain why: *

Please provide first and last name of any spouse/partner who may also be requesting quotes and have him/her complete a second term quote request

Lifestyle Details

In the last five years, have you used tobacco in any form including cigars, cigarettes, pipe, chew, or nicotine products such as nicotine patch, nicotine gum, or e-cigarettes / vapor? *

Yes No Unknown Unanswered

Please list each tobacco/nicotine type: *

Tobacco/Nicotine Type 1

Amount/Frequency *

Example: 1 pack daily

Date Last Used *

Add Tobacco/Nicotine Type

Have you used marijuana in the last 5 years? *

Yes No Unknown Unanswered

Please describe details including

Frequency (# per week, month or year)
Date last used
How it is used (smoked, ingested, edibles, vape, etc.)
Recreational or medical use
- If medical use, do you have a prescription and what is the diagnosis?

Any/all information helps us find the best rates *

Do you consume alcohol? *

Yes No Unknown Unanswered

Type of Alcohol *

How Much? *

How often? *

Are you, or do you intend to become, a member of the Armed Forces, including the Reserves, or on alert? *

Yes No Unknown Unanswered

If yes, please explain. *

Are you planning to reside or travel outside the United States in the next 2 years? *

Yes No Unknown Unanswered

Please list planned cities, countries, purpose, dates, duration, etc... *

Have you ever been charged with a DUI/DWI, reckless driving, or had your driver’s license revoked or suspended? *

Yes No Unknown Unanswered

Please provide details such as violation type, arrest date, conviction date and any loss of license/probation/recommended counseling: *

Have you had any other motor vehicle/moving violations in the past 5 years? *

Yes No Unknown Unanswered

Please provide description (such as: speeding, accident, red light running, etc...) and approximate month/year of any violations: *

Health Details

Weight (lbs) *

Gender *

Male Female

Are you currently pregnant? *

Yes No Unknown Unanswered

What's your approximate due date? *

How much weight have you gained so far? *

Are you currently undergoing IVF? *

Yes No Unknown Unanswered

Please provide details including treatments, procedures and dates *

Even if not currently pregnant, have you had a history of gestational diabetes, complications or a history of multiple births with any pregnancies? *

Have you had any weight loss or gain of more than 10 lbs. in the last year? *

Yes No Unknown Unanswered

Please indicate amount of weight gain or loss, and reason: *

Have you EVER been diagnosed with, treated for, hospitalized for or been advised to seek treatment for:

High blood pressure? *

Yes No Unknown Unanswered

Please provide date of diagnosis, medications (name, dosage, and frequency), last date of treatment (if applicable), & last reading/test result *

Example: Diagnosed with elevated blood pressure 2 years ago – take 20 mg Lisinopril daily – last reading 128/82

High cholesterol or high triglycerides? *

Yes No Unknown Unanswered

Please provide: Specific condition/diagnosis, date of diagnosis, any medications (name, dosage and frequency), last date of treatment (if applicable), and last reading/test result *

Example: High Cholesterol – July 2014 – take Crestor 20mg / day – had physical in May – readings were great

Heart attack or coronary artery disease? *

Yes No Unknown Unanswered