Competitive Term Life

PROPOSAL AND QUOTE REQUEST
(* required fields)
AGENT INFORMATION
*Officer's Name: Bank:
*Licensed Agent name:
(Enter name of licensed agent or "same as above")
Location:
*Officer/Agent's email: Officer/Agent's Phone:

PRODUCT QUOTE INFORMATION
*Face Amount:       
 
10
15
20
30
Lifetime
Select additional terms
* Limited Plan Availability
*Years of Coverage:   (check all that apply)
   
Alternate Face Amount: *Customer's resident state:

CUSTOMER INFORMATION
*Customer Full Name:   *Gender: (M or F) *Date of Birth: (mm/dd/yyyy) Age:
       
*Customer height and weight:      

      Height: Feet Inches

Weight:  (pounds)    
       
*Tobacco Use: (please select one)      
      YES IF prior tobacco usage, please list date quit
      NEVER USED TOBACCO Not Sure whether customer now uses tobacco

ADDITIONAL QUOTE INFORMATION

Does your Customer take any prescription medication? YES   NO
If yes, please advise for what condition and attempt to spell the medication:

Did either of Customer’s parents experience cardiovascular disease or cancer PRIOR TO THEIR AGE 60? YES   NO
If yes, give any details that may be helpful:

Run all quotes for excellent health: YES NO

Other input that may impact your Customer’s risk class, such as driving record, height/weight, cholesterol, blood pressure, or other personal and family history:


REMARKS:


Prior to submitting this form, please make sure all the fields with an "*" are completed.

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