Substandard Life Quote

The quote you have requested requires that you complete the following survey as completely and accurately as possible. Once submitted the information will be e-mailed to our office(s) and we will expedite your request. This information will be kept confidential and will be used for quote purposes only. We look forward to serving you.

NOTE: If you are interested in a second-to-die quote then you must complete this entire form again for the proposed second insured.

 

Contact Information
*First Name
Last Name
*Email Address
Work Phone
Home Phone
City
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Quote Information
Date of Birth	(mm/dd/yy)
Gender	Male Female
Have you used tobacco?	Yes No
If yes, specify date (mm/dd/yy) of last use:	Cigarette Cigar Pipe Chewing Tobacco
Height	(ex: 5'8")
Weight	(ex: 150 lbs)
Are you a private pilot?	No Yes
Amount needed	$ 25,000 $ 30,000 $ 35,000 $ 40,000 $ 45,000 $ 50,000 $ 60,000 $ 70,000 $ 80,000 $ 90,000 $ 100,000 $ 125,000 $ 150,000 $ 175,000 $ 200,000 $ 225,000 $ 250,000 $ 275,000 $ 300,000 $ 325,000 $ 350,000 $ 375,000 $ 400,000 $ 425,000 $ 450,000 $ 475,000 $ 500,000 $ 550,000 $ 600,000 $ 650,000 $ 700,000 $ 750,000 $ 800,000 $ 850,000 $ 900,000 $ 950,000 $1,000,000 $1,250,000 $1,500,000 $1,750,000 $2,000,000 $2,250,000 $2,500,000 $2,750,000 $3,000,000
Policy Type	Term Permanent Second-to-Die
General Medical
Describe your Health / Medical impairment or Special risk:
Date Diagnosed:	(mm/dd/yy)
Medications (Include Dosage):
Cholesterol / Ratio	/
Blood Pressure
Types and dates of surgery or hospital treatments:
Family History ("Father", "Mother", "Siblings") Give Reasons for any Deaths prior to age 60:
Since diagnosis, list any lifestyle changes: (Exercise Program, Stopped Smoking, etc.)
Additional Considerations/ Requests
Please give any additional comments you feel appropriate for this quotation.
Please click on the "Submit Request" button to send us your quote request. An Agent will contact you shortly.

 

 

 

 

 

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