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Life Insurance Request for Quote - MICHIGAN ONLY!

Complete our online form below for yourself and/or other family members to receive a no-obligation quote tailored to each individuals specific age, health, and coverage needs.

To request an additional illustration for a family member, reopen the form after submitting your first request, complete for the next individual and submit again.

TERM LIFE INSURANCE
The minimum amount of coverage you may apply for TERM life insurance is:

Issue Age Face Amount

1-14 $10,000 to 20,000

15-49 $100,000

50-75 $50,000

UNIVERSAL LIFE INSURANCE
The minimum amount of UNIVERSAL life insurance coverage you may apply for is $50,000.

ALL INFORMATION IS KEPT CONFIDENTIAL

MICHIGAN RESIDENTS ONLY! Please complete the following information.
Email Address *
Name *
Address *
City *
State
Zip Code *
Daytime Phone (optional)
UNDERWRITING QUESTIONNAIRE
Date of Birth (month, date, year)
Gender	Male Female
Height
Weight
Have you used any tobacco products?	NONEpast36months YES in past 36 months NONE in past 60 months YES in past 60 months NEVER used
Have you been treated or sought treatment for:
drug or alcohol abuse?	Yes No
moderate/severe asthma, chronic bronchitis, Crohns, diabetes, epilepsy(seizure w/in 2yrs), gastric/peptic ulcer(treated w/in 2yrs),chronic kidney/liver disease, mental illness, multiple sclerosis, ulcerative colitis?	Yes No
for depression within the past 2 years?	Yes No
cardiovascular heart disease, chronic obstructive pulmonary disease, emphysema, stroke(inc. TIA), vascular disease?	Yes No
Have you or do you plan Gastric by-pass surgery, or have you lost or gained more than 10 pounds in the past two years?	Yes No
Have you lost a parent or sibling to an early death due to heart attack, stroke or cancer?	No Yes prior to age 50 Yes prior to age 55 Yes prior to age 60 Yes 61 or older
If answered yes to loss of parent/sibling above give age & cause of death
Is your blood pressure normal?	Yes with medication Yes withOUT medication NO Medication
Is your cholesterol level normal?	Yes with medication Yes withOUT medication NO Medication
In past 5 years have you received 3 or more traffic violations /or been convicted of driving under the influence?	Yes No
Any hazardous occupation or hobbies?	Yes No
Plans to travel to underdeveloped or unstable countries?	Yes No
Give due date if pregnant:
Explain all yes answers above and any other health, family or lifestyle issues that may affect your rate or insurability.
Please list medications you take and the reason.
I AM INTERESTED IN:
Death Benefit * Amount of:
Duration of plan -TERM Insurance Only!	10 years 15 years 20 years 30 years
Guaranteed level term/level premium	Yes No
Return of Premium level term?	Yes No
Universal Life Insurance?	Yes No
Comments or questions?
Completing a request for an illustration (quotation) does not guarantee that a policy will be issued or obligate you to accept a policy.

* Required

PRIVACY POLICY	DISCLOSURES	SECURITY	BUSINESS CONTINUITY PLAN	FINRA	MEA	MESSA