Life Insurance Quote Questionnaire
Thank you for reaching out to our agency! We’ll be happy to provide you with some quotes, but first, we just need to gather some basic information to determine the best rates. Please fill out the form below as best as you can, and we will respond within 24 business hours. To obtain a similar quote for a spouse/domestic partner/significant other as well, simply scan the link again after submitting this survey and complete the form with their information.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email: (If no email, please type "n/a"):
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please select what type of policy you are interested in (select all that apply):
*
Term 10 year
Term 15 year
Term 20 year
Term 30 year
Term Express (no medical exam)
Whole life (100 year pay)
Whole life (65 year pay)
Whole life (20 year pay)
Please fill in the amount of coverage you would like:
*
Please select:
*
Male
Female
Date of Birth:
*
Are you a tobacco user:
*
Cigarettes
E-Cigarettes
Smokeless tobacco
Cigars
No
How would you rate your current health status?:
*
Excellent
Good
Fair
Poor
Do you have an pre-existing medical conditions?:
*
No
Yes (if yes, please explain below)
If you answered yes to a pre-existing medical condition, please explain here:
*
1. Have you ever been denied coverage by a life insurance company?
*
No
Yes (if yes, please explain below)
If you answered yes to a previously being denied, please explain here:
*
What is your Height:
*
What is your Weight:
*
Please list any medications taken on a regular basis, or mark "none":
*
Please list medications, dosage for each, & how long you have been taking the medication. If none, please enter "none".:
*
Please list any known medical conditions, or mark "none":
*
Please list any past surgeries, or mark "none":
*
Disclaimers and Quick Notes: -The more accurate the information that you supply, the more accurate the quote will be. -Any information entered in this questionnaire is considered confidential, is SOLELY for quoting purposes, and will not be sold or used for ANY other purposes. -All life insurance policies are subject to underwriting purposes - The quotes that will be supplied from this questionnaire are intended to give an estimated cost and will not constitute an official rate or offer of insurance.
Signature
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