Life Insurance Quotation Form
Fill the fields below accurately and we will return back to you in a short time
If you have any questions call or text the office at 405-992-4120
www.christinadavisagency.com
How much debt do you have?
Choose Amount
$0
$5,000
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
$400,000
$450,000
$500,000
$550,000
$600,000
$650,000
$700,000
$750,000
$800,000
$850,000
$900,000
$950,000
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
Final Expenses
Choose Amount
$5,000
$6,000
$7,000
$8,000
$9,000
$10,000
$15,000
$20,000
$25,000
$30,000
No Final Expenses Needed
How much income replaced?
Choose Amount
$30,000
$35,000
$40,000
$45,000
$50,000
$60,000
$65,000
$70,000
$75,000
$80,000
$85,000
$90,000
$95,000
$100,000
$110,000
$120,000
$130,000
$140,000
$150,000
$160,000
$170,000
$180,000
$190,000
$200,000
$220,000
$230,000
$240,000
$250,000
$260,000
$270,000
$280,000
$290,000
$300,000
$310,000
$320,000
$330,000
$340,000
$350,000
$360,000
$370,000
$380,000
$390,000
$400,000
$410,000
$420,000
$430,000
$440,000
$450,000
$460,000
$470,000
$480,000
$490,000
$500,000
$600,000
$700,000
$800,000
$900,000
$1,000,000
How many years of income replacement?
Choose Amount
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
How much do you owe on your mortgage?
Choose Amount
$20,000
$30,000
$35,000
$40,000
$45,000
$50,000
$60,000
$65,000
$70,000
$75,000
$80,000
$85,000
$90,000
$95,000
$100,000
$110,000
$120,000
$130,000
$140,000
$150,000
$160,000
$170,000
$180,000
$190,000
$200,000
$220,000
$230,000
$240,000
$150,000
$260,000
$270,000
$280,000
$290,000
$300,000
$310,000
$320,000
$330,000
$340,000
$350,000
$360,000
$370,000
$380,000
$390,000
$400,000
$410,000
$420,000
$430,000
$440,000
$450,000
$460,000
$470,000
$480,000
$490,000
$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
How much education would you like to cover?
Choose Amount
$0
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
$50,000
$55,000
$60,000
$65,000
$70,000
$75,000
$80,000
$85,000
$90,000
$95,000
$100,000
$150,000
$200,000
$250,000
$300,000
Approximately, how much do you have in readily available assets?
Choose Amount
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
$400,000
$450,000
$500,000
$550,000
$600,000
$650,000
$700,000
$750,000
$800,000
$850,000
$900,000
$950,000
$1,000,000
$1,250,000
$1,500,000
$1,750,000
$2,000,000
How much life insurance do you currently have?
Choose Amount
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
$400,000
$450,000
$500,000
$550,000
$600,000
$650,000
$700,000
$750,000
$800,000
$850,000
$900,000
$950,000
$1,000,000
$1,250,000
$1,500,000
$1,750,000
$2,000,000
Name
First Name
Last Name
Email
Phone Number
Please enter a valid phone number.
What State Do You Live In?
Choose State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
How Tall Are You?
Choose Height
4'10
4'11
5'0
5'1
5'2
5'3
5'4
5'5
5'6
5'7
5'8
5'9
5'10
5'11
6'0
6'1
6'2
6'3
6'4
6'5
6'6
6'7
6'8
6'9
6'10
6'11
7'0
7'1
7'2
7'3
7'4
7'5
7'6
What is your gender?
Female
Male
What is your Birthday?
*
/
Month
/
Day
Year
Date
Do you smoke?
No
Nicotine
Cannabis
Have You Ever Dealt With Any of These Health Issues?
None
High Blood Pressure
High Cholesterol
Type 1 Diabetes
Type 2 Diabetes
High Blood Pressure
Sleep Apnea
Coronary Artery Disease
Cardio Vascular Disease
Arrhythmia
Atrial Fibrillation
Stroke or TIA
Blood Clotting Disorder
Kidney Disease
Hepatitis A, B, or C
Cancer - Any Form
DUI, Alcohol, or Drug Treatment
Other
Signature
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Day
Year
Date
Hour Minutes
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