life insurance request for quote illustration

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Life Insurance Request for Quote - MICHIGAN ONLY!

· How Much Insurance Do I Need?
· Group Term Life Insurance
· Types of Life Insurance
· Life Insurance Glossary

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.

TERM LIFE INSURANCE
The minimum amount of coverage you may apply for TERM life insurance is (Your age for insurance is your closest birthday):

Issue Age Face Amount

1 thru age14 $10,000 to 20,000 minimum

15 thru age 49 $100,000 minimum

50 thru age 75 $50,000 minimum

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	Age and cause of death or N/A (Not Applicable)
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 had 3 or more traffic violations /or been convicted of D.U.I.* ?	Yes No *Driving Under the Influence
Any hazardous occupation/hobbies?	Yes No
Plans to travel to underdeveloped or unstable countries?	Yes No
Pregnant? Due date::	Date Due or N/A (Not Applicable)
Explain above "yes" answers & other health, family or lifestyle issues that may affect premium or insurability.
List medications you take and reason:.
I AM INTERESTED IN: (click on the policy type below for a brief description)
Death Benefit * Amount	(i.e. 100,000, 150,000, 200,000, 250,000, etc.)
Duration of plan	10 years 15 years 20 years 30 years ( Term Life Insurance ONLY)
Guaranteed Level Term/Level Premium *	Yes No
Return of Premium Level Term? *	Yes No
Comments or questions?
Completing a request for an illustration (quotation) does not guarantee that a policy will be issued or will it obligate you to accept a policy.
* Required

You will have the opportunity to request an additional illustration for yourself or
another family member once you have submitted your completed request above.

PRIVACY POLICY	DISCLOSURES	SECURITY	BUSINESS CONTINUITY PLAN	FINRA	MEA	MESSA