LIFE INSURANCE QUOTE
The Kessler Insurance Agency
What Agent would you like?
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Agent Mynde Kessler
Agent Jeremy Rushing
Agent Mechelle Wood
Agent Linette Amoss
Agent Candice Turner
How much life insurance do you want?
10-25K (burial policy)
26K-100K
101K-250K
251K-500K
Other (ex. 1 mil)
What kind of life policy do you want?
Term Life (10, 15, 20, or 30 yr options)
Whole Life (builds cash value)
Universal Life (grows cash value based on index funds)
Burial Policy (10-25K options)
Primary Insured
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First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
/
Month
/
Day
Year
Date
Height / Weight
*
Ex. 5'6 / 160 lbs
Have you used any form of tobacco in the last year?
*
No
Cigarettes
Snuff
Vape
Have you had/currently being treated for?
*
No current diagnoses/treatments
Cancer
Anxiety/Depression
Heart Attack/Surgery
Diabetes
AIDS/HIV
High blood Pressure/High Cholesterol
Other (Ex. Weight loss Surgery)
Year diagnosed and medications currently taking?
Diagnosis, Name of Prescription, Dosage, Frequency
Primary Care Physician / Health Care Provider
Name & phone number (or none)
Do you currently have life insurance at work or with another carrier?
Yes
No
How much life insurance do you currently have?
0
10K-100K
101K-250K
251K-400K
401K-500K
501K or more
Does your work life insurance continue if you leave your job?
Yes
No
I don't know
N/A
Acknowledgement: All information provided in this form is kept confidential and the information entered will be used to give you a life quote using this limited information. Therefore, you understand that the rate provided is before any underwriting has been completed and is subject to change.
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Thank you for filling out your information!
Please, let us know how you heard about us and the best time to contact you.
Are you interested in any of these additional insurance products?
Auto Insurance
Home/Renters Insurance
Health or Long Term Care Insurance
Other
How did you hear about us?
Social Media (Facebook, LinkedIn)
Google
Realtor/Loan Officer
Referral (provide name in "other", we love to send them a thank you to recognize them)
Other
What is your preferred contact?
*
Text message
Phone call
E-mail
When is the best time to call/text you?
*
Morning
Afternoon
Other
Submit
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