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Key Person Life Insurance Quote
All information is kept strictly confidential and used ONLY to prepare an accurate quote for you
10
Questions
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1
Your state of residence:
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2
Applicant's date of birth:
-
Date
Month
Day
Year
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3
Applicant's gender:
Male
Female
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4
Applicant is a smoker?
YES
NO
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5
Applicant's Health Class:
Your best guess as to what health class applicant fits into:
Standard (Average health)
Standard Plus (Above average, minor health issues)
Preferred (Excellent health)
Preferred Plus (Excellent health. No medications. No family history of disease)
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6
Type of Insurance required:
10-year term
15-year term
20-year term
25-year term
30-year term
Whole life
Universal life
I'm not sure
10-year term
10-year term
15-year term
20-year term
25-year term
30-year term
Whole life
Universal life
I'm not sure
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7
Face amount required:
$25,000
$50,000
$75,000
$100,000
$125,000
$150,000
$200,000
$250,000
$300,000
$400,000
$500,000
$600,000
$700,000
$800,000
$900,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
$3,000,000
$3,500,000
$4,000,000
$4,500,000
$5,000,000
$7,500,000
$10,000,000+
Not sure what I need
$500,000
$25,000
$50,000
$75,000
$100,000
$125,000
$150,000
$200,000
$250,000
$300,000
$400,000
$500,000
$600,000
$700,000
$800,000
$900,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
$3,000,000
$3,500,000
$4,000,000
$4,500,000
$5,000,000
$7,500,000
$10,000,000+
Not sure what I need
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8
What's your name?
First Name
Last Name
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9
Thanks {name:firstname}. What is your phone number?
please note: your contact info is kept private, not shared and is only used to discuss your quote with you.
Please enter a valid phone number.
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10
And what email address can we send your quote to?
please note: your contact info is kept private, not shared and is only used to discuss your quote with you.
example@example.com
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11
Agent Email
example@example.com
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