• Life Insurance Preliminary Quote Request

    Life Insurance Preliminary Quote Request

  • Complete this brief form to receive personalized life insurance options based on your coverage needs and budget. This is a preliminary screening and quote request only. Quote amounts may change after medical evaluation has been completed. 

  • Basic Information

  • Format: (000) 000-0000.
  • 4. Who are you requesting life insurance coverage for?
  • 6. Insured's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Coverage & Budget

  • 8. What type of life insurance are you interested in?
  • 9. How much life insurance coverage (face amount) are you interested in?
  • 10. What monthly premium would comfortably fit your budget?

  • Before You Answer the Health Questions

  • IMPORTANT: Please answer all health questions with the INSURED in mind.

    Policy Owner: The person who owns and controls the policy and is generally responsible for the premiums. The owner and insured may be the same person or different people.
    Insured: The person whose life is being covered. All health questions below refer to this person.
    Beneficiary: The person or entity designated to receive the life insurance death benefit.
    If you are requesting coverage for yourself, answer the health questions about yourself. If you are requesting coverage for someone else, answer them based on that person.

  • Basic Health Information

  • 11. Insured's Sex (for insurance quoting purposes)
  • 14. Does the insured currently use nicotine or tobacco products?
  • If Yes, what type?
  • 15. Has the insured been diagnosed with or treated for any significant medical conditions?If Yes, briefly list the condition(s), such as high blood pressure, diabetes, heart condition, cancer, etc.
  • 16. Is the insured currently taking any prescription medications?If Yes, list the medication(s) and what they are prescribed for.

  • Timing & Consent

  • 18. When are you looking to obtain coverage?
  • Disclaimer: This form is for preliminary screening and quote purposes only and is not an application for insurance. Quotes are estimates and are subject to carrier eligibility, underwriting, and final approval.

  • REQUEST MY FREE QUOTE

  • Simonne & Co. Financial Solutions | 205-600-3708 | simonnecofinancial@gmail.com
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