Life Insurance Quote Request

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How much coverage do you need? * This field is required.It's ok to be unsure! We can do a needs analysis/calculation. Most people choose tend to fall into one of these brackets of coverage: $100,000-$500,000, $500,000-$1,000,0000 or $1,000,000 to $2,000,000. There are people who need more than $2,000,000 of coverage. Everyone's situation is unique. It's also possible to purchase more than one policy for different needs.
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How long do you want coverage locked in for?* This field is required.Choose all that you would like to see quotes for!
10 Year Term
15 Year Term
20 Year Term
25 Year Term
30 Year Term
35 Year Term
40 Year Term
Lifetime Coverage
I'm not sure
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What state are you located in?* This field is required.Life insurance goes by the state you are physically located in at the time of application. If you will be moving by the time you are buying a policy, please enter the new state. Right now, we are just doing price comparisons.
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Gender* This field is required.
Male
Female
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Date of birth* This field is required.
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How tall are you?* This field is required.
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What is your current weight? Have you lost more than 10lbs in the past year(other than pregnancy or diet/exercise)?* This field is required.
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Have you used any of the following forms of tobacco or nicotine in the past 12 months?* This field is required.
Cigarette
Nicotine patch/gum
Vape
Chew
Cigar
Smokeless tobacco
Marijuana
None
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Please list the frequency you use any tobacco/nicotine products, incl. marijuana.
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List all physical health conditions you have, what year they were diagnosed and the severity(mild, moderate or severe).
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List all mental health conditions you have, what year they were diagnosed and the severity(mild, moderate or severe).
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List all currently prescribed medications(even if not taken).
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If you had prior medications list all prescriptions within the last 5 years.
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List any surgeries in the last 5 years.
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Do you have any immediate family members(parents & siblings) that have been diagnosed with cancer, stroke, heart disease or diabetes before the age of 61?* This field is required.
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What is your US Citizenship/Residency status?* This field is required.For example: US Citizen, Permanent Resident, Visa Holder, etc...
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Please list your foreign travel(outside the US) in the last and upcoming 2 years. List approx. dates, locations, length of stay and whether trips are for leisure or occupation. * This field is required.
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Do you have any criminal history?* This field is required.
YESNO
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Do you have any bad debits such as charge offs, collections and liens?* This field is required.
YESNO
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Have you ever filed for bankruptcy? If yes, what type? When was it discharged?
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Do you have 2 or more moving violations, DUI's or license suspensions on your driving record in the last 5 yrs?* This field is required.
YESNO
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Do you participate in dangerous hobbies such as aviation, scuba diving, rock climbing, racing, etc..* This field is required.
YESNO
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What is your annual, gross(before taxes) income?* This field is required.Life insurance companies use this to determine eligibility for coverage requested.
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Choose your occupation type.* This field is required.
Employed W2 Wages
Independent Contractor or 1099
Homemaker
Retired
Unemployed
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Are you a member of the military whether Active, Reserve or National Guard?* This field is required.
YESNO
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What is your occupation? * This field is required.List your title and a brief description of your job duties.
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Are you involved in any aviation for either employment or pleasure as a pilot or crew member?* This field is required.
YESNO
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What type of license(s) do you have?
Commercial
Private
Student
ATR - Airline Transport Rating
IFR - Instrument Flight Rating
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What year was your license originally issued?
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For military pilots and crew members please provide your branch of service and specify duties. Please note if you are a member of the precision flying team and if you fly for proficiency only.
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What type(s) of aircraft do you fly or occupy as a crew member?
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How many solo hours do you have?
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How many hours have you flown in the past 12 months?
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How many hours do you estimate to fly in the next year?
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Are you a pilot or a crew member?
Pilot
Crew member
Both
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Provide the estimated date of your last flight as a pilot, crew member and passenger. List all that apply.
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Have you had any accidents, violations or groundings?
YESNO
38
Do you have any flights planned over inaccessible remote areas? If so, please provide details.
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Do you fly outside of the United States? If so, please provide details.
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Either now or in the next 12 months will you be flying in the Civil Air Patrol?
YESNO
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In the next 2 years will you change to Commercial or Military flying? Please explain.
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Do you fly over 3,000 feet?
YESNO
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While not recommended, excluding aviation coverage can reduce your price coverage. Are you interested in this?
YESNO
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Full Name* This field is required.
First Name
Last Name
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Phone Number* This field is required.
Please enter a valid phone number.
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Are you comfortable receiving text messages at the above phone number?* This field is required.
YESNO
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E-mail* This field is required.
example@example.com
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I understand this form submission is NOT an application for coverage and that coverage CANNOT be bound by this entry. This is for a quote ONLY.* This field is required.Please call Melissa Schreur directly if you are in need of immediate assistance (305)373-3666.
YESNO
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What insurance plans would you like to review? Can be now or in the future!
Life - Term and/or Lifetime, Burial, Child Plans
Disability - Individual, Protect Your Paycheck
Dental, Vision, Hearing - Can be individual or combined together
Hospital Indemnity Plans - Reimbursement for hospital stays, ambulance, emergency room
Critical Illness - Cancer, Heart Attack, Stroke, etc…
Personal Insurance - Home, Auto, Recreational Vehicles, Personal Items, Liability, etc...
Annuities - 401 Rollover, Retirement planning, Safe Money Accounts(Upside Potential w/o the downside risk)
Business Owners - Buy Sell Agreement, Key Employee Coverage, Employee Benefits - Life, Accident, Hospital, Cancer, etc…
Business Owners Disability - Business Overhead Expense Coverage, Key employee
Commercial Insurance - Workers Comp, Auto, General Liability, Cyber Liability, etc...
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