Business Life Insurance Quote Request

The following information is needed to provide an accurate business life insurance quote. You will not be inundated with calls and texts from multiple agents. The information you provide will not be sold, resold, or shared with anyone without your written permission.

General Life Insurance Quote Request Form

Tax-Free Retirement Quote Request Form

You will not be pressured into taking on a policy before you are ready.

To avoid paying income tax when used for retirement planning, as per IRS Code 7702, this is a max-funded IUL (Index Universal Life) policy. Therefore, we need certain personal information to enable the insurance carriers to approve you:

If more than one person is to be insured, complete this form for one person at a time. When first entry in completed, “Submit”, Refresh, and submit the next, and so on.

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Business Name

Complete Business Address

Business Phone & Website

Ownership Structure (Corp, LLC, Partnership, Proprietorship, etc.)

How Many Owners?

What is the nature of the business?

When did the business begin operation?

Please Choose All That Apply

• Key Person Insurance
• Succession Planning (Death of an owner)
• Retirement Planning (Tax-Free Income well in excess of total premiums paid)
• Infinite Banking (Borrowing at reduced rates while continuing to earn compound interest.)
• Asset Protection (Shielding cash resereves from legal attachment.)
• Living Benefits (Incapacitation Insurance)
• Other (If there is another benefit that you would like addressed, please detail in the space provided below.)

Please explain "Other".

Name of the person being insured *

First

Last

Email of the person being insured *

Phone of the person being insured. *

State where the person being insured resides: *

Date of Birth of the person being insured. *

Age of the person being insured (I can write policies on people from 15 days old to 85 years old.)

Gender at Birth of the person being insured?

• Female
• Male

Is the person being insured a Smoker? *

• Yes
• No
• Quitting in Progress

Height *

Weight *

How would you consider your state of health?

• Excellent
• Good
• Fair
• Poor

If your health is fair or poor, why? Please be very specific. Please include dates and prescription medications.

FOR KEY PERSON INSURANCE: What is the monitary value of losing this person? If more than one person is to be insured, complete this form for one person at a time. When first entry in completed, "Submit", Refresh, and submit the next, and so on.

FOR SUCCESSION PLANNING: How many company owners are there?

FOR SUCCESSION PLANNING: How much is the business currently worth?

FOR RETIREMENT PLANNING: How much annual tax-free retirement income does the person being insured need? *Please choose one of the followingLess than $25,000$25,000 – $50,000$50,000 – $100,000$100,000 – $150,000$150,000 – $200,000$200,000 – $250,000$250,000 – $300,000$300,000 – $500,000$500,000 – $750,000$750,000 – $1,000,000$1,000,000 +Unknown

FOR RETIREMENT PLANNING: For how many years does the person being insured like to receive this income?Please choose one of the following:10 Years15 Years20 Years25 Years30 Years35 Years

FOR RETIREMENT PLANNING: How old would the person being insured like to be when he/she retires?:Please choose one of the following:45 years old50 years old55 years old60 years old65 years old70 years old75 years oldUnsure

FOR RETIREMENT PLANNING: Does the person being insured have any retirement accounts currently? (Please be specific)

What ignited your current interest?

Name of the person making this request if different from insured.

First

Last

Phone & Email of the person making this request (if different from the person being insured)

Relationship to the insured.

General Comments

How did you hear about us?

Submit