Insurance Quote IIB

Life Insurance Quote Request
Agent/Advisor Information
Agent/Advisor Name*

First NameLast Name
E-Mail*
Phone Number*
Agent/Advisor State*
Client Information
Client Name*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Clients State*
Height:
Weight:
Tobacco?*
Plan Design
Life Insurance Type (check all that apply)*

TermWhole Life (Permanent)Indexed Universal Life (IUL)Hybrid/Linked benefitSimplified IssuedGuaranteed IssuedGuaranteed Universal Life (GUL)Variable Universal Life (VUL)Other
Policy Length (check all that apply)*

5 year10 year15 year20 year25 year30 year
Guaranteed to Age:
UL's Typically run to age 120
Solve for Face Amount or Premium?*

Face Amount/ Death BenefitPremium
Premium Amount*
Face Amount / Death Benefit *
Can have multiple entries
Schedule of Premium*
Rider Selection

Waiver of PremiumGuaranteed InsurabilityChronic IllnessAccidental DeathChild RiderLong Term CareOther
Number of Children
Underwriting Class*
Does the applicant currently have any disorder, condition (including pregnancy), disease, or defect or are they currently taking medication prescribed or provided by a medical or other practitioner for any disorder, condition (including pregnancy), disease, or defect other than a cold, cough, flu, or allergies?*

YesNo
please explain to above question
During the last five years, has the applicant been admitted to the hospital, mental health facility, or other institution for observation, rest, diagnosis, or treatment?*

YesNo
please explain to above question*
During the last five years, has the applicant had life, disability, or health insurance declined, cancelled, withdrawn, postponed, changed, or rated?*

YesNo
please explain to above question*
Within the last five years, has the applicant been diagnosed for disease or disorder by a medical profession for any of the following: heart, chest pain, high blood pressure, cholesterol, cancer or tumors, diabetes, lungs, kidneys, liver?*

YesNo
please explain to above question, List medications*
Additional Notes for medications
Additional Notes or Preferences on Quotes:
For Questions Please call 317-663-0061
Should be Empty:

Life Insurance Quote Request

Agent/Advisor Information

Client Information

Plan Design

For Questions Please call 317-663-0061