Tax-Free Retirement Income QUOTE Request

The following information is needed to provide an accurate 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 Life Insurance Quote Request Form

General Life Insurance Quote Request Form

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

To avoid paying income tax, as per IRS Code 7702, this is a max-funded IUL (Index Universal Life) policy, therefore, you have to be approved. Therefore, we need certain information to enable the carriers to approve you for Tax-Free Retirement Income:

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Name of person for whom tax-free income is intended: *

First

Last

Email *

Phone *

State where lives: *

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 Annual Tax-Free Retirement Income Do You 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

How Many Years Would You Like This Income?Please choose one of the following:10 Years15 Years20 Years25 Years30 Years35 Years

How old would you like to be when you retire?:Please choose one of the following:45 years old50 years old55 years old60 years old65 years old70 years old75 years oldUnsure

Do you 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

Relationship to the insured.

General Comments

How did you hear about us?

Submit