Your Full Name (required):
Company Name (if applicable):
Your Email Address (required):
The best Telephone Number to reach you at(required):
The Best TIME to reach me by telephone:
Your Primary Address (required):
Number of years at this address (optional):
Mailing Address (if different from above):
Your Occupation (required - and used to see if there are any applicable discounts):
Marital Status: SingleMarriedDivorcedWidowed
Spouse's Full Name (if applicable):
Spouse's Occupation (if applicable):
Do you have current/previous coverage? If so, how long?
Have you ever been canceled, denied or have your insurance lapse?yesno
Please explain any lapse, cancelations in your previous coverage (if applicable):
When would you like coverage to begin
What is your current height & weight
Do you smoke?yesno
What type of Life Insurance are you looking for (if you know):Whole Life (Full Term)Term Life (5 year increments)Child (0-17 years old)Adult (18-70 years old)I don't know what I need
Desired Coverage Amount
Who would you like to list as the Beneficiary?
Please list their address and telephone number:
Who would you like to list as the Contingent Beneficiary?
Please list the Contingent Beneficiary's address and telephone number:
Does the child have, or, during the past 10 years, been diagnosed or treated by any medical professional for: Cancer (other than basal cell skin cancer), liver disease, Lupus, Kidney disease, ulcerative colitis, diabetes, sugar or albumin in urine, seizures, paralysis, depression or other mental or nervous system disorders, congenital defect or deformity, impairment of sight (if not corrected), impairment of hearing (if not corrected), impairment of speech, heart murmur, rheumatic fever, any other heart disorder (other than controlled hypertension), asthma or any other lung disorder? YesNo
Has the child tested positive for HIV, or been diagnosed as having AIDS Related Complex (ARC) or Acquired Immu Deficiency Syndrome (AIDS) caused by the HIV infection or contrived from such infection?YesNo
Has any Medical Professional, during the past 3 years, advised that the child have any surgery, or be hospital confined, that has not been done?YesNo
Have you smoked one or more cigarettes within the past 24 months?YesNo
Do you have, or, during the past 10 years, been diagnosed or treated by any medical professional for: Cancer (other than basal cell skin cancer), heart disease (including heart attack), stroke, angina, arterial disease of the heart or extremities, congestive heart failure, diabetes, liver disease, Alzheimer's disease, multiple sclerosis, Lupus, kidney disease, ulcerative colitis, Crohn's disease, seizures, depression, brain or nervous system disorders, emphysema, chronic lung disorder, mental or nervous disorder, alcoholism, or drug use?YesNo
Do you have, or during the past 10 years, have you been diagnosed or treated by any medical professional for: Acquired Immune Deficiency Syndrome (AIDS), positive result of a Human Immunodeficiency Virus (HIV) test, or AIDS Related Complex (ARC)?YesNo
Are you currently confined to a hospital or nursing facility, or have you been advised by any medical professional during the past 3 years to have any surgery, additional diagnostic testing, hospital or nursing facility confinement, and have not yet done so?YesNo
In the past 5 years, have you been refused, rejected, or postponed for life insurance?YesNo
Mortgage - What is the current pay-off amount of your home mortgage?
Replacement Income - How many years do you think your family would need your income to sustain their way of life?
and how much income per year would they need?
Final Expenses - The average funeral expenses start around $10,000 and go up from there. How much would you like to plan to set aside for Final Expenses?
College Expenses - If the insured member has children, they may consider college expenses into their life insurance policy in order to assure their children can afford the rising cost of higher education. You can do this by multiplying the average yearly tuition cost by the number of years per degree for each child. (example: $10,000 x 4 years x 3 children = $120,000). How much would you like to plan to set aside for College Expenses?
Debt Reduction - The LAST thing you want to leave your family is a pile of bills. Estimate the amount of outstanding debt you have including vehicle loans, personal loans, medical bills, and credit cards:
Charity & Legacy - You've built your life around your family; your community, and the people and organizations you love. Enter an amount you would like to leave your family or an organization that will be used to honor your legacy:
Please include any Additional Information that you feel would help expedite your quote:
I certify that all information in this quotation/application has been truly and accurately answered. I also understand that the information on this quotation/application will be relied upon to determine insurability and that incorrect information may result in coverage being voided, subject to the policy Incontestability ProvisionPlease Check this box if you agree:
To cut down on the amount of computer-generated "spam" we get through forms, we've implemented a "Captcha" below. Please place the numbers/letters listed below in the box below them before pressing the "send" button
Insert these numbers
Into this form:
Press "Send" to Submit this Quotation: