Life Insurance

Life Insurance

Provide us with this basic information and we can provide you with a general understanding of cost and options. Use this form for EACH individual that may be interested in a Life Insurance Quote.
It is important to get started today...

We shop your needs against dozens of life insurance carriers to find the best fit for your needs. To get started, simply answer the questions below. We are able to provide you with estimates of cost after shopping your profile against our many carriers. Once you determine the Term, Benefit Amount and are comfortable with the estimated premium, we start an application process. Each carrier has slightly different information needs and most may require blood work and/or a medical exam. From start to finish, the process can take a couple weeks, so understand that life insurance is not like purchasing car or home insurance with immediate approvals and binding.
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Let's Get Started - we need some basic personal information

Please provide accurate answers to the best of your abiltiy.
Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone*
Please enter a valid phone number.
What is your Home State?
Which State do you consider your residence State.
Gender*

MaleFemale
Date of Birth*

MonthDayYear
MM-DD-YYYY
Height*
Please indicate Height in Feet and Inches (i.e. 5' 9")
Weight*
In pounds (lbs)
Have you used / do you use Tobacco Products*

Yes - I currently use tobacco productsYes - but it's been more than 5 years since I used anyNo - have never used
Do you have any medical condition or congenital diagnosis that you need to make us aware of and/or that you believe could impact your application?

YesNoI don't know - we may need to talk about it
Please indicate if your genetic parents or siblings have had any of the following diagnoses BEFORE the age of 60:*

CancerDiabetesHeart DiseaseNone
In general, how would you describe yourself:

I am in great health, I exercise, eat healthy, and have no medical issuesI am in good health and have no medical issuesI could lose a few pounds and/or have some health concernsI have some serious health issues I am working throughPrefer not to answer
Which kinds of insurance are you interested in (select all that apply)?

Term LifePermanent LifeLong Term DisabilityDisability IncomeI don't knowOther
Do you have a coverage amount in mind?
(Dollar amount -no worries if you do not, we can help you determine coverage levels.)
Do you have a Term or Length of Coverage in mind?

10 Year15 Year20 Year25 Year30 YearMore than 30 YearNot Sure - I need some help determining the appropriate termOther
Riders you might want to add to your policy (see below for general descriptions). These are optional and you do not have to make a selection. If you would like to add options, you can select as many as you are interested in.*

Accidental Death BenefitWaiver of PremiumReturn of PremiumChild RiderNone - I am not interested in these at this time
Note that there is a increased cost impact to your base Life Insurance policy when adding additional riders/options such as these.

Accidental Death Benefit - if death is the result of an accident, the insurance policy could pay an addiditonal death benefit to the policy holder. This rider may also pay out certain amounts while the policy holder is alive if they suffer a qualifying injury casued by accident.

Waiver of Premium - this optional rider may waive insurnace premiums if the policyholder becomes critically ill or physically impaired. This rider may have age and health requirements.

Return of Premium - if you outlive the polcy term, this rider may pay some of your policy premiums spent on the policy.

Child Rider - this is an add-on that pays out a death benefit if one (or more than one) of your children pass away. This serves as a safety net for you so you can focus on family instead of worrying about funeral expenses.
We Have NO MEDICAL EXAM options

We have carriers that offer rapid approvals. These options, in most cases, provide approvals in hours or days (not weeks) and for most applicants do not require paramedical or lab exams. If you would like to consider this option, please check the box below. Please note that because these options offer no exam underwriting, the cost could be higher than the traditional Life Insurance application and review process which requires more comprehensive questionnaires and medical/lab screening.
I would like to also run quotes for the No Medical Exam option

Yes PleaseNo Thank you
Date

MonthDayYear
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Please don't forget to click Submit to The Musico Agency Team
Please note, coverage cannot be bound, changed, or confirmed through email, text, this form, or voicemail. You must speak with a licensed agent. The Musico Agency, LLC dba Goosehead Insurance - The Musico Agency and (in California) The Musico Agency - Goosehead Insurance Agency, is an Insurance Agency/Brokerage licensed in AZ #3003572126; CA #6008386; NV #3804381; OH #1445049, TN #3002000604, ID #3002198889, NM #3002654359.
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Life Insurance

It is important to get started today...

Let's Get Started - we need some basic personal information

We Have NO MEDICAL EXAM options