Life Insurance Quote Form

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
Date of Birth

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

Other
Policy Length (check all that apply)
Guaranteed to Age:
UL's Typically run to age 120
Solve for Face Amount or Premium?
Premium Amount
Face Amount / Death Benefit
Can have multiple entries
Schedule of Premium
Rider Selection

Other
Number of Children
Underwriting Class
Smoker?
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?
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?
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During the last five years, has the applicant had life, disability, or health insurance declined, cancelled, withdrawn, postponed, changed, or rated?
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?
please explain to above question, List medications
Additional Notes for medications
Additional Notes or Preferences on Quotes: Example (If you want your IUL ran for cash value or if you want to see withdrawals at a certain age Etc...)
For Questions Please email illustrations@indins.org
Should be Empty:

Life Insurance Quote Request

Agent/Advisor Information

Client Information

Plan Design

For Questions Please email illustrations@indins.org