Life Insurance Quote Request
If you are seriously seeking life insurance coverage that meets your current and support your future goals, then complete and submit this form to receive a complimentary quick quote. Quotes are not final amounts. Quotes are estimated amounts based on your age, health, and gender. Please allow 24 to 48 business hours to receive a 30-min complimentary conversation about your quotes. ~Michelle "Chelley" Dallas-Scott, Your Trusted Life Insurance Broker
Current Life Insurance Situation
Respond to the required questions below.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
City/State
*
Who needs a quick quote?.
*
Me
My spouse/significant other
My child/children/dependents
My grandchild/grandchildren
My parent(s)
My business partner(s)
Other
Does the above selected person/people currently have life insurance coverage?
*
Please Select
Yes
No
Pending
Some have it, and others do not.
I'm not sure.
FOR THOSE WITH life insurance: list their name, date of birth, amount of coverage, the monthly amount for the coverage, and the company it is with. Type n/a if applies.
*
FOR THOSE WITHOUT life insurance: list their name, date of birth, state born in, smoking status (if quit smoking, when?, and if do some smoke, what?) height, and weight. Type n/a if applies.
*
Who has been diagnosed with medical conditions (dealing with the heart, lungs, brain, bones, diabetes, high blood pressure, high cholesterol and such), and/or has been prescribed medications (whether taking the prescriptions or not) in the last 7 years? Type n/a if applies.
*
Who is diagnosed with mental health conditions (dealing with ADHD, anxiety, bipolar, PTSD, schizophrenia, and such), and/or has been prescribed medications (whether taking the prescriptions or not) in the last 7 years? Type n/a if applies.
*
To your knowledge, did you are someone else you know request a medical report from the Medical Information Bureau (MIB) for the person/people denied life insurance coverage?
*
Please Select
Yes
No
I don't know.
I never heard of the MIB.
n/a
List the names of those who applied for life insurance within the last 6 to 12 months and was denied coverage. Type n/a if applies.
*
Life Insurance Needs, Goals, and Budget
Respond to the required questions below.
Select all the types of life insurance coverage you are interested in or need.
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accidental death
final expense whole life
traditional whole life
term life
indexed universal life (IUL)
I need help deciding.
Select all that what you want your life insurance coverage to do?
*
cover my end of life expenses (funeral, burial, homegoing celebration)
pay my family's mortgage and other debts
pay me directly if I become ill, injured, or disabled and cannot work
cover my children's and/or grandchildren's future college or business expenses
supplement my retirement income
I need help deciding.
Do you have at least 2 retirement savings accounts? Type n/a if applies.
*
Please Select
Yes
No
I need help with this.
n/a
Do you have an emergency savings account? Type n/a if applies.
*
Please Select
Yes
No
I need help with this.
n/a
After you pay bills, obligations, debts, expenses, about how much can you comfortably put aside to fund life insurance protection for coverage? Type n/a if applies.
*
List any concerns or questions you have about life insurance address that you want to address during our phone call. Type n/a if applies.
*
Do you rent or own... if rent how, much a month? If own, how much a month and how many years left to pay off home? Type n/a if applies.
Submit
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