Request a Life, Disability Income, Long Term Care, or Annuity Quote

Quotes

Please take a moment to fill out the form for the product you are interested in illustrating below.  Once submitted, one of our representatives will contact you to provide the quote.  Please note this information will be kept confidential and will be used for quoting purposes only. Thank you!

* Required fields.

Agent Information:

Agent/Broker Name*:

Agency Name:

Agency Address:

City:

State:

Zip:

Phone:

Fax:

Email*:



Client Information:

Client:

DOB:

State:

Gender:

 Male Female

2nd Client:

DOB:

State:

Gender:

 Male Female

Face Amount: ($)

Premium: ($)

Years to Pay:



Life One:

Type:

 Preferred Best Preferred Standard Plus Standard

Table Rating:

Smoker

 Non-Smoker Smoker Nicotine

Type and frequency of tobacco or nicotine use



Life Two:

Type:

 Preferred Best Preferred Standard Plus Standard

Table Rating:

Smoker

 Non-Smoker Smoker Nicotine

Type and frequency of tobacco or nicotine use



Life Coverages

Term:

Universal Life:

Whole Life:



Additional product details, Riders, or requests.



Additional details pertaining to health, family history, medications, avocations, foreign travel, etc.

Agent Information:

Agent/Broker Name*:

Agency Name:

Agency Address:

City:

State:

Zip:

Phone:

Fax:

Email*:



Client Information:

Client Name:

DOB:

State of Issue:

Occupation:

Duties/Job Description:

Annual Income:

Gender:

 Male Female

Smoker:

 Smoker Non-Smoker

Business Owner:

 Yes No

If Yes,

No. of Employees:

Yrs. in Business:

Group LTD Inforce:

 Yes No

If Yes,

Detail:

Individual LTD Inforce:

 Yes No

If Yes,

Details:



Individual Policy Information:

Monthly Benefit:

SIS:

Elimination Period:

Benefit Period:

Riders:

Other Information:



Overhead Expense/Buy Out Policy Information:

Monthly Benefit:

Value of Business:

Percent of Ownership:

Elimination Period:

Benefit Period:

Riders:

Agent Information:

Agent/Broker Name*:

Agency Name:

Agency Address:

City:

State:

Zip:

Phone:

Fax:

Email*:



Client Information:

Client Name:

DOB:

Underwriting Class:

 Preferred Standard Sub-Standard

Spouse Name:

DOB:

Underwriting Class:

 Preferred Standard Sub-Standard

State of Issue:

Marital Status:

Full Partner Discount:

 Yes No



Policy Information:

Monthly/Daily Benefit: ($)

Optional Riders:

Elimination Period: (Days)

Benefit Period: (Years/Days)

Select Inflation Option:



Additional details and health concerns, medications, etc.

Agent Information:

Agent/Broker Name*:

Agency Name:

Agency Address:

City:

State:

Zip:

Phone:

Fax:

Email*:



Client Information:

Client Name:

DOB:

Spouse Name:

DOB:

State of Issue:

Qualified or Non-Qualified:

 Qualified Non-Qualified



If Single Premium Immediate Annuity:

Amt. of Single Premium:

Or Benefit Amount:

Monthly or Annual Benefit:

 Monthly Annual

Benefit Starting in One Month or One Year:

 One Month One Year

SPIA Type:

Additional details.



Single Premium Deferred Annuity:

Amt. of Single Premium:

Withdrawals

 Yes No

If Yes,

Amount

Mode

 Monthly Annual

Starting Date:

End Date:

Annuitization Age:

SPDA Type:

Additional details.



Flexible Premium Deferred Annuity:

Amt. of First Year Premium:

Amt. of Future Premium:

Frequency of Future Premium:

Withdrawals

 Yes No

If Yes,

Amount

Mode

 Monthly Annual

Starting Date:

End Date:

Annuitization Age:

FPDA Type: