• "Quote-It-Once" Universal/Whole Life

    AGENT INFORMATION - Please answer the following questions.

    Agent Name: Agency: MKG Insurance Agency CA License #0J03013 Phone: (559) 412-7248 Address: 4021 N Fresno Street Suite 107 City: Fresno State: CA

  • ZIP Code: 93726 Email: support@mkginsuranceagency.com

     

  • Frequency: 7. Past Tobacco Usage: None Cigarettes

    Other (Specify)[ Months Since Last Use:

  • 8. Medications & Purpose: Medication:

  • 9. Height: 10. Weight: 11. Cholesterol:

    Purpose: Dosage & Frequency: ] lbs]

  • 12. HDL Ratio: 13. Blood Pressure:

    Deceased (Cause:Heart DiseaseCancerOther[

  • 16. Engages in Hazardous Activities: Pilot Scuba Diving Skydiving Racing Other (Specify)[ 17. Other Impairments (Diabetes, Cancer, Hypertension, etc: Yes (Details in Additional Notes) No 18. Replacement Case: Yes No If Yes, Previous Underwriting Class: Date of Replacement:

  • Date of Replacement
     / /
    2 digit month, 2 digit day, 4 digit year

  • 19. Client Type: Primary Insured Second Insured 20. Insurance Plan: Survivorship Plan Term Universal Life (UL) Whole Life Blended Whole Life

    21. Face Amount(s): 22. Premium: [$ 23. Payment Mode: Annually Semi-Annually Quarterly Monthly (PAC) 24. Premium Solve For: Endowment

  • 25. Additional 1st Year Premium: [$ 26. Premium from 1035 Rollover: Yes No 27. Withdrawals/Loans: Beginning Age: Amount: [$ Cash Left at Maturity: [$

    Cash Value at Age[]Amount [$ Number of Years to Pay Premium

  • Waiver of Premium Accidental Death Child Term Rider ($ Spouse Term Rider ($ 29. Purpose of Coverage: Cash Accumulation Death Benefit 30. Other Companies Being Quoted: 31. Their Rates: 32. Preferred Company for Quote:

  • 34. Preferred Submission Method: Fax Email Mail 35. Include Additional Documents (Select all that apply): Applications Licensing Miscellaneous Forms (Specify)[

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  • Should be Empty: