Life Insurance QUOTE Request

The following information is needed to provide an accurate 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.

Business Based 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.

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Name of person to be insured *

First

Last

Email *

Phone *

State where insured Resides *

Date of Birth *

Age: (I can write policies on people from 15 days old to 85 years old.)

Gender at Birth?

• Female
• Male

Are you 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.

How Much Life Insurance Coverage Do You Need? *Please choose one of the following$25,000 – $50,000$50,000 – $100,000$100,000 – $250,000$250,000 – $500,000$500,000 – $750,000$750,000 – $1,000,000$1,000,000 – $2,500,000$2,500,000 – $5,000,000$5,000,000 – $10,000,000$10,000,000 +Unknown

Why now?

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

First

Last

Phone & Email of the person making this request

Relationship to the insured.

GENERAL LIFE: What type of life insurance are you interested in? Choose all that apply:

• ACCIDENTAL DEATH POLICY – (Only pays out if death is the result of an accident)
• ANNUITIES – (Annuities are investments issued by insurance companies that can be used to help build a guaranteed income stream or a retirement nest egg.)
• FINAL EXPENSE POLICY – (Burial insurance, $5,000-$50,000 death benefit. From 50-85 years old.)
• INCOME PROTECTION POLICY- (The death benefit is usually 2X to 5X annual income.)
• INFINITE BANKING – (The ability to borrow money from a Cash-Value policy while continuing to earn compounded interest on the same money.)
• JUVENILE POLICY – (From 2 weeks old to 18 years old with the focus on the growth of cash-value)
• LEGACY CREATION POLICY – (Ensuring the beneficiaries receive a substantial payout. Death Benefit can exceed $100,000,000+)
• LIVING BENEFITS – (A policy in which the death benefit can be accessed while the insured is still alive.)
• MORTGAGE PROTECTION POLICY – (A policy that pays off, or pays down your mortgage)
• PERMANENT POLICY – (A policy for life with increasing cash value)
• TAX-FREE RETIREMENT POLICY – (Retirement income is generated by this policy, tax-free. Depending on age and health at the time the policy is originated, and the way then [policy is designed the income can be as much as 3,600%+ of premiums paid.)
• TERM POLICY – (A policy that terminates after a specified number of years, usually 10-30 years)
• UNSURE – (I need help in determining what policy type would work best for me.)
• OTHER – (If not listed above, please be very specific as to what you are looking for)

Other (General Life)

BUSINESS LIFE: (If Applicable) What type of business related life insurance are you interested in? Choose all that apply:

• BUY/SELL AGREEMENT FUNDING – (A Buy/Sell agreement details what happens if a business partner dies, and provides the funds to pay off the deceased partner’s heirs)
• KEY MAN/WOMAN – (A policy that pays the company if an important employee or officer dies)
• RETIREMENT PLANS – (Policies that generate substantial cash-value that far exceeds the premiums)
• SUCCESSION PLANNING – (Policies that detail what happens if one or more of the corporate owners were to die)
• UNSURE – (I need help in determining what policy type would work best for me.)
• OTHER – (If not listed above, please be very specific as to what you are looking for)

Other (Business Life)

Does the proposed insured currently have life insurance?

• Yes
• No
• Not sure

If "Yes" to above, please provide specifics.

General Comments

How did you hear about "Life Insurance Safe Zone" ("Safe Zone Life")?

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