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
