Insurance Quote Request

Client Information
Insurance Quote Request

Life, long-term care or disability. Complete the form below and we'll run the market.
Is this quote request for:
Advisor Requesting Quote

First NameLast Name
Advisor Information
Advisor Email
Do NOT put Seth Freeman. Put YOUR Advisor.
Name (you may use initials)

First NameLast Name
Date of Birth

MonthDayYear
State
Gender
Client Email (optional)
example@example.com
Health Information
Height and Weight
Any tobacco use in the past 5 years?
Please list the type of tobacco used, the frequency, and the most recent use.
List all previous and current medical conditions.
Anything from high blood pressure to sleep apnea to a heart attack.
List all medications currently prescribed.
Is this quote for Term or Permanent?
What term length(s) would you like illustrated?
How much death benefit do you want illustrated? You may request multiple amounts.
What policy riders would you like to see illustrated?
What type of permanent product do you want illustrated?
How much death benefit do you want illustrated? You may request multiple amounts.
What premium mode would you like illustrated?
If Limited Pay - How many years?
What is the primary strategy?
Is an LTC rider important?
Client Information
Is the Insured married?
1st Insured's Name

First NameLast Name
2nd Insured's Name

First NameLast Name
1st Insured's Date of Birth

MonthDayYear
2nd Insured's Date of Birth

MonthDayYear
1st Insured's Gender?
2nd Insured's Gender?
Does 1st Insured smoke?
Does 2nd Insured smoke?
Insured(s) Resident State
1st Insured: Please list any known current or past medical conditions
2nd Insured: Please list any known current or past medical conditions
Policy Design - We have streamlined the design and will provide you with an LTC overview displaying multiple illustrations and design options.
Health Information
Height and Weight
Tobacco User?
List all previous and current medical conditions.
Anything from high blood pressure to sleep apnea to a heart attack.
List all medications currently prescribed.
Vocation Questions
Occupation
Job Title
Description of job duties
Years Employed
Annual Earned Income
Annual Unearned Income
Annual Bonus
Amount of time worked from home:
Self-Employed?
Business Owner?
Approximate number of full-time employees
Former occupation and income if less than 1 full year in business
Policy Design
Preferred benefit period:
Elimination Period
Would you like inflation protection?
Maximum benefit is typically 3/4 of annual income. How much benefit are you looking for?

Other
Current Coverage
Is there current DI coverage in force?
Is the current policy group or individual?
Is this additional or replacement?
What is the current monthly benefit amount?
Please make any additional notes that you think are important here.
Thank You! Disability quotes typically take 2-3 days to produce. We will be reaching out to a number of companies and will provide you with a comparison sheet as soon as possible. We will contact you if there are any additional quetions.
Human Check
Should be Empty:

Client Information

Insurance Quote Request

Advisor Information

Health Information

Client Information

Policy Design - We have streamlined the design and will provide you with an LTC overview displaying multiple illustrations and design options.

Health Information

Vocation Questions

Policy Design

Current Coverage