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? * Full UnderwritingSimplified Issue Coverage Type: * —Please choose an option—TermAnnual Renewable TermULVULIULWLSingle Premium WL Term —Please choose an option—10 Year15 Year20 Year25 Year30 Year Survivorship: —Please choose an option—SULSVULSWL Rate Class * —Please choose an option—Best RatePreferredStandardRatedNot Sure Rated Level (if applicable) Coverage Amount * Client budget per month for this plan $: Client Information * Full Name * Phone * Email * State * —Please choose an option—AKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVIVAWAWVWIWY Gender * —Please choose an option—FemaleMale Date of Birth * Age * Nicotine Use * Current Nicotine Use * —Please choose an option—NoneCigarettesCigarsPipeDipChewNicotine GumECigOther 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. * —Please choose an option—YesNo 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?....—Please choose an option—YESNO Name of medication Are you taking medication to lower cholesterol?...—Please choose an option—YESNO Name of medication Aviation/Avocation * NoneFlyingRacingSky DivingScuba DivingOther (describe below) Description: Citizenship/Residency/Travel * US Citizen? * —Please choose an option—YESNO 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? —Please choose an option—YESNO 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? —Please choose an option—NoneMoving ViolationReckless DrivingDWI or DUILicense SuspensionLicense Revoked Provide dates & details: 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. By clicking and submitting this form with my name, phone number, and e-mail address, I agree that I am at least 18 years of age. By clicking and submitting this form, I understand that I am enrolling in an ongoing marketing campaign about insurance services and other options from Empower Brokerage or a licensed agent, and I will receive phone calls and e-mails (even if that phone number is on any Do Not Call Registry or is a mobile number). If you want to opt out of receiving future e-mails from Empower Brokerage, you can do so at any time by clicking the “unsubscribe” button in our e-mail. For more details, see our Privacy Policy.
