Marc Sollee Agency Life Quote Request

Primary Insured Name (as on drivers license) *

Your Name

Primary Insured Date of Birth *

Date

Social Security Number *

Phone Number *

Email *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

What is your reason for needing life insurance? *

Taking care of family's future Mortgage Protection Other Debt Protection Business Related

How much life insurance do you feel you need? *

Are you interested in a term policy, a permanent policy, or a blend of both? *

Do you currently have life insurance? If so, how much? *

Height *

Weight *

Drivers License Number *

Drivers License State *

Country/State of birth *

Are you a US citizen? *

Employer's Name *

Occupation and Duties *

Number of years at current employer *

Annual household income *

How much life insurance does your spouse currently have? *

Who would you like to be the beneficiary? They must have an insurable interest in you *

How are you related to the beneficiary? *

Beneficiary's Date of Birth *

Date

Beneficiary's social security number if you have it

Beneficiary's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Beneficiary's Phone Number *

Please enter a valid phone number.

Name of Contingent Beneficiary (Back Up) *

Your relation to the Contingent Beneficiary *

Contingent Beneficiary's Date of Birth *

Date

Contingent Beneficiary's social security number if you have it

Contingent Beneficiary's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Contingent Beneficiary's Phone Number *

Please enter a valid phone number.

Who is your primary Physician? *

Your Physician's Phone Number *

Please enter a valid phone number.

Your Physician's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

What was the date and reason for your last visit to your physician? *

What are your parent's ages? Are they both living? If deceased, at what age did they pass and what was the cause? *

Do your parent's have/had Alzheimer's, Cancer, Heart or Polycystic Kidney Disease, Familial Adenomatous Polyposis, Huntington's Disease, ALS, or Parkinson's Disease? *

# of Siblings, their ages, and are they living? *

Do your siblings have/had Alzheimer's, Cancer, Heart or Polycystic Kidney Disease, Familial Adenomatous Polyposis, Huntington's Disease, ALS, or Parkinson's Disease? If yes, at what age were they diagnosed? *

Describe any of your existing health conditions *

If applicable

Have you had any major surgeries? *

Do you have any military experience? *

Are you a pilot, student pilot, or crew member? *

Any foreign travel upcoming (tickets purchased)? *

Any risky activities such as rock climbing, skydiving, etc.? *

Have you had a DUI? If so, what date? *

Have you had any at fault auto accidents in the last 5 years? If so, what dates? *

Have you had any driving citations in the last 5 years? If so, what kind and what dates? *

Have you ever been to rehab? *

Do you have any felonies? *

Any illegal drug use? *

Marijuana use? *

How many alcoholic drinks do you have per week on average? *

Tobacco use? *

Have you ever attempted suicide? *

Have you lost more than 15 pounds in the last 12 months? *

Have you been hospitalized for more than 5 days in the past 2 years? *

Have you been able to perform normal work duties for the past 90 days? *

List any medications you are currently taking *

If applicable

If the proposed insured is under 18 years of age, what is the parent's full name, date of birth, social security number and drivers license number?

Please list some days and times that you are available for an in-home exam. The examiner will take a blood and urine sample as well as ask a few health related questions. The exam usually takes about 20 minutes total. *

EFT Information -
Bank Routing Number Bank Account Number
Preferred day of the month for drafts
*This information will only be used if your life insurance policy is approved

How did you hear about us? *

(ie. Google, Yelp, Friend, Realtor, Loan Officer)

Any other details that will be helpful?

Thank you for your interest in Life Insurance from The Marc Sollee Agency!

We will reach out to you right after we submit your application to Farmers New World Life with follow up information.

We look forward to protecting you and your family!

Marc Sollee Agency, LLC

143 E Germann Rd Ste 110
Gilbert, AZ 85297

480-900-8010

www.farmersagent.com/msollee

Marc Sollee Agency Life Insurance Request