Life Quote – Empower Brokerage

Step 1

Fields labeled with an * are REQUIRED

Agent Information *

Agent Name *

Agent Email *

Agent Phone *

Fill out the form below as completely as possible.

We will prepare your quote, based on the information you provide.

CLICK HERE to download a Fact Finder form to help you gather important information.

CLICK HERE to download a Generic Underwriting Reference to quickly help you determine rate class.

If you experience any problems, please contact us at (888) 539-1633. All personal information is protected by HIPAA regulations.

Plan of Insurance Requested *

Purpose for Coverage: *

Full Underwriting or Simplified Issue? *

Coverage Type: *

Term

Survivorship:

Rate Class *

Rated Level (if applicable)

Coverage Amount *

Client budget per month for this plan $:

Step 2

Client Information *

Full Name *

Phone *

Email *

State *

Gender *

Date of Birth *

Age *

Nicotine Use *

Current Nicotine Use *

Describe if "Other"

Quantity per month

Former tobacco use: (List each type of tobacco, quantity and frequency used, and date of last use)

Build *

Height *

ft.

in.

Weight *

lb.

Family History *

Family history is a consideration for each rate class

To your knowledge, is there any family history (parent or siblings) with onset of disease prior to age 60 due to:

Cardiovascular disease
Cerebrovascular disease
Diabetes
Cancer

Please answer YES or NO. *

If YES, please provide full details with impairment, age at onset and age at death if deceased:

Father:

Mother:

Siblings:

Blood Pressure/Cholesterol

Latest BP reading:

Latest total cholesterol (mg):

Latest cholesterol/HDL ratio:

Are you taking medication for blood pressure?....

Name of medication

Are you taking medication to lower cholesterol?...

Name of medication

Aviation/Avocation *

NoneFlyingRacingSky DivingScuba DivingOther (describe below)

Description:

Citizenship/Residency/Travel *

US Citizen? *

If no, provide type and expiration date of visa, green card status, and length of time in the USA:

Any future plans to live or travel outside the USA?

If yes, provide purpose, cities, countries, frequency, and duration:

Driving History

Have you had any of these motor-vehicle-related incidents in the past 10 years?

Provide dates & details:

Step 3

Medical History *

Have you ever had, been told you had, or been treated for any of the conditions listed?
If yes, check the box and explain each:

Alcohol Abuse

Alzheimer's/dementia/cognitive impairment

Asthma

Cancer

Cirrhosis

COPD

Coronary artery or cerebrovascular disease

Crohn's Disease

Depression/anxiety

Diabetes

Drug Abuse

Epilepsy

Heart Murmur/Valve Disease

Hepatitis

Irregular Heartbeat/Palpitations

Kidney Disease

Lupus

Multiple Sclerosis

Peripheral Vascular Disease

Rheumatoid Arthritis

Sleep Apnea

Stroke

Other

List dates, diagnosis, details & treatments. Also enter names, addresses, and phone numbers of all consulted physicians.
(refer to Common Medical and Non-Medical Impairment for critical underwriting factors):

Please verify that all the information you have entered is correct, then click Submit

By checking this box, you consent to receive text messages from Empower Brokerage and/or a licensed Empower Brokerage agent. These messages may include marketing messages (e.g., promotions, reminders) and follow-up communications related to your inquiry to the number provided, which may include the use of an autodialer. Message and data rates may apply. Message frequency varies. You can unsubscribe at any time by replying STOP or clicking the unsubscribe link.

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