Request A LifeQuote

Agent Name

Please Quote:

Super Preferred/Preferred Plus Nonsmoker
Preferred Non-smoker
Standard Non-smoker
Impaired Risk Non-smoker

Preferred Smoker
Standard Smoker
Impaired Risk Smoker

Underwriting Assistant

E-mail
Phone
Client Name
State
Gender

Male Female

Date of Birth / /
or Actual Age
or Nearest Age
Face Amount
Waiver of Premium Yes No
Childrens Rider Yes No
Amount Mode
Is this spouse coverage? Yes No Is this business partner coverage? Yes No
Client's Medical Conditions, Medications, and Answers to Pertinent Questions:
Please Quote the Following Products... With the Following Carriers...

5 Year Term
10 Year Term
15 Year Term
20 Year Term
30 Year Term
Universal Life (* See below)
Whole Life (* See below)
Second to Die (* See below)

 
Best Quote Possible
Banner Life
First Colony Life
First Penn-Pacific
Lincoln Benefit
Security Connecticut		 United of Omaha
U.S. Financial
West Coast Life
If Universal Life, Whole Life or 2nd to Die, please complete one of the following:

Solve For Premium

Years to Pay Premium
Additional Amount (1035)
Solve for Cash Value of
At Age

Specify Premium

Premium Amount:

Additional Amount (1035):

Years to Pay Premium:

Min. Premium to Guarantee the Contract

15 Years
20 Years
30 Years
40 Years
Lifetime Guarantee
Notes or Concerns:
Illustration Delivery:
E-mail in Adobe PDF file format
E-mail of important numbers only
Fax
U.S. Mail
Call with premium numbers
Will pick up
Other
Please Include:
Application kit for quoted state
A.M. Best Report
Current Vital Signs Report
Contracting
Marketing Materials: please specify
AgentSuite