First Name *
Last Name
Street Address
City
* State Zip
* Email
Fax
Please double check your e-mail
address so you can receive your quote quickly
Day Phone
Evening Phone
Do you have coverage now?YesNo Amount $ Type
How much are you (or were you) paying?
Are You Planning To Replace Any Existing Policies? Yes No
* How soon are you wanting to get your family covered?
ASAP
2-3 months
4-6 months
What do you LIKE MOST about your current or previous coverage?
What do you LIKE LEAST about your current or previous coverage?
* What are the most important benefits that you want in a life
insurance plan?
* What kind of policy are you looking for? Individual Family Children
Only
Please fill in every available space.
This is vital for you to receive an ACCURATE, and PROFESSIONAL
life insurance quote.
* Applicant
* Age * Ht.
* Wt. * Tobacco Yes No
* I Would Like a Quote For$50,000$100,000$150,000$200,000$250,000$300,000
$400,000$500,000$750,000$1,000,000 Other
Type
* Spouse Age
* Spouse Ht. * Spouse Wt.
* Spouse Tobacco Yes No
* I Would Like a Quote For$50,000 $100,000 $150,000$200,000$250,000$300,000
$400,000$500,000$750,000$1,000,000 Other
Type
Ages
of the children to be covered
I Would Like a Quote For$5,000 $10,000 $15,000$20,000 Other
Type
* Explain
which applicant might have a Pre Existing Health Condition or currently taking medication
Other
Comments that might be helpful for us to know
For Most Accurate Quote Please Complete Following Questions.
Yes No Has not used tobacco or nicotine in any form (including nicotine patches or gum) in the last 12 months
Yes No Has not used tobacco or nicotine in any form (including nicotine patches or gum) in the last 36 months
Yes No Has no family history of two or more natural parents or siblings diagnosed as having, having died of, coronary heart disease, internal cancer or melanoma prior to age 60
Yes No Has had no death of a natural parent prior to age 60 due to coronary heart disease, internal cancer or melanoma. If parents are living and younger than 60 they are in good health which is defined here as no diagnosed history of coronary heart disease, internal cancer or melanoma
Yes No Has blood pressure of 145/90 or less (if treated, blood pressure must have been under treatment for at least one year and maintained favorable average readings)
Yes No Has untreated blood pressure that is consistently less than: 140/90 if age 60 or younger; 150/90 if age 61 or older; (A prior history of elevated blood pressure may disqualify the applcant.)
Yes No Has a cholesterol count of 250 or less and a total cholesterol/HDL ratio of 7 or less
Yes No Has a cholesterol count of 250 or less and total cholesterol/HDL ratio of 6 or less
Yes No Has an untreated cholesterol count of 220 or less and an total cholesterol/HDL ratio of 5 or less. 240 or less may be acceptable if all other factors are favorable
Yes No Has no history of diabetes
Yes No Has no history of internal cancer or melanoma
Yes No Has no history of drug or alcohol abuse
Yes No Has no other significant health problems
Yes No Has not had more than two moving violations in the past three years, or a DWI, DUI or reckless driving conviction or license suspension in the past five years
Yes No Is not a private pilot or strudent pilot (private pilot can qualify if Aviation Exclusion Rider is accepted)
Yes No Has not engaged in hazardous sports (e.g. racing, skydiving) during the past two years
Yes No Is a United States citizen residing permanently in the United States with no plans for extended foreign travel to countries or areas considered hazardous by North American
Yes No Is not active duty military risk