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: