PHILAM LIFE INSURANCE QUOTATION FORM

1
Name of Applicant / Policy Owner* This field is required.
Mr.
Mr.
Mrs.
Ms.
Atty.
Dr.
Engr.
First Name
Middle Name
Last Name
2
Gender* This field is required.
Male
Female
3
Date of Birth* This field is required.
Date
Month
Day
Year
4
Mobile Number* This field is required.
09xx
xxxxxxx
5
Email Address* This field is required.
example@example.com
6
Occupation* This field is required.
7
Are you also the insured person? Click "No" if someone else would be the life insured (ex: your children)* This field is required.
No
Yes
8
Name of the Insured Person* This field is required.
Mr.
Mr.
Mrs.
Ms.
Atty.
Dr.
Engr.
First Name
Middle Name
Last Name
9
Gender* This field is required.
Male
Female
10
Date of Birth* This field is required.
Date
Month
Day
Year
11
Smoker?Did you use any nicotine product in the past 12 months
YESNO
12
Occupation* This field is required.
13
What is your current life stage?* This field is required.
Please Select
Please Select
Single Professional
Married w/o children
Full Nester (w/ dependent children)
Empty Nester and Retiree
Business Owner
14
As a single professional, which of the following goal is your 1st priority?* This field is required.
Create wealth. Tax sheltered investment in perminent life insurance
Income Protection against disability or critical illness
Money for health, medical and dental treament
Mortgage insurance
Other
15
As a married person without children yet, which of the following goals is your 1st priority* This field is required.
Income protection agaist disability or critical illness
Protect your partner
Create wealth. Tax sheltered investment in perminent life insurance
Money for health, medical and dental expenses
Other
16
As a full nester with dependent children, which of the following goals is your 1st priority* This field is required.
Mortgages/debts eliminatoin, to ensure the surviving spouse is debt free.
Protect your family by providing income replacement until children become indepedent.
Income protection against risks of critical illness or disability
Save for retirement. Tax sheltered invesment perminent life insurance.
Other
17
As an empty nester or retiree, which of the following is your 1st priority?* This field is required.
Increase retirement savings. Create wealth through tax sheltered invesment in life insurance
Pay for long term care's health and medical expenses.
Create wealth for your children or grandchildren.
Protect your assets/estate from tax erosion.
Money for final expenses: burial costs and final tax
Other
18
As a business owner, please select which of the following goals is your 1st priority* This field is required.
Fulfill Buy/Sell Agreement
Key Person Insurance
Create tax sheltered investment vihecle in the corporation
Eliminate tax when winding up the company
Estate planning and succession planning
Other
19
Which benefits would you want to be included for your plan? (all benefits are available for kids to adults)* This field is required.
Life Insurance
Disability insurance
Critical Illness Coverage
Long Term Care Insurance / Retiree Health Assist
Individual health insurance for self employee or retiree
20
How much would you be willing to set aside annually for this goal? * This field is required.The rule of thumb is 5% of annual income or 2% of your networth
Ex: 25,000-35,000
Should be Empty: