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Life Quote

    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? *

    Coverage Type: *

    Term

    Survivorship:

    Rate Class *

    Rated Level (if applicable)

    Coverage Amount *

    Client budget per month for this plan $:


    Client Information *

    Full Name *

    Phone *

    Email *

    State *

    Gender *

    Date of Birth *

    Age *

    Nicotine Use *

    Current Nicotine Use *

    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. *

    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?....

    Name of medication

    Are you taking medication to lower cholesterol?...

    Name of medication

    Aviation/Avocation *

    NoneFlyingRacingSky DivingScuba DivingOther (describe below)

    Description:

    Citizenship/Residency/Travel *

    US Citizen? *

    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?

    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?

    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

    Other

    List dates, diagnosis, details & treatments. Also enter names, addresses, and phone numbers of all consulted physicians.

    (refer to Common Medical and Non-Medical Impairment for critical underwriting factors):

     

    Please verify that all the information you have entered is correct, then click Submit

     

    AGREEMENT: By clicking and submitting this form with my name, phone number, and e-mail address, I agree that I am at least 18 years of age. I agree that I am the current authorized user of the phone number and e-mail address submitted. I expressly consent to opt in to receive e-mails and text messages from Empower Brokerage about health insurance, life insurance, Medicare Supplements, Medicare services and other options. Empower Brokerage is an independent insurance agency and is not affiliated with the federal Medicare program. By clicking and submitting this form, I understand that I am enrolling in an ongoing marketing campaign by Empower Brokerage, and I will receive text messages and e-mails as part of the ongoing Empower Brokerage marketing campaign. By clicking and submitting this form, I am authorizing Empower Brokerage to provide my information to a licensed agent, and I am authorizing the agent to contact me. I am also authorizing the agent to call, e-mail, or text me at the phone number and email address I provided (even if that phone number is on any Do Not Call Registry or is a mobile number). I am consenting to calls with Empower Brokerage being recorded and monitored.
    Standard text and data rates may apply. You can opt out of receiving text messages from Empower Brokerage at any time by replying to an Empower Brokerage text message with “unsubscribe”, “stop”, “end”, “no”, or “opt out”. If you want to opt out of receiving future e-mails from Empower Brokerage, then you can do so at any time. Please click the “unsubscribe” button in our e-mail. Empower Brokerage values your privacy and will not share your personal information with any other business or persons.