Life Insurance Quote Request
Great day! 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 MO#8368596 (multi-state licensed)
Current Life Insurance Situation
Respond to the required questions below.
Name
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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?.
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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? If do some smoke, what?) height, and weight. Type n/a if applies.
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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.
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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.
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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?
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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.
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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.
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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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