Life Insurance Quote Request | Standard Marketing

Life Insurance Quote Request

Fields Marked by an Asterisk are required. The Agent Information, Client Information and Policy Information sections may be opened and closed without risk to the data to better accommodate your internet browser.

Agent Information

Name: *

Email Address: *

Phone Number: *

State of Sale: *

Client Information

Please answer these questions to request your life quote. If you would like to provide additional information, please do so in the "Notes" box. Hit send when you are finished and our Life Department will quote several carriers to ensure that you and your client are getting the best product at the best rate.

Client Name: *

DOB: *

Gender: *

Current Height (inches):

Current Weight (lbs):

Tobacco User?: *

Type of Tobacco:

If Stopped, When?:

Heart/CAD History:

Heart/CAD Details:

If Cancer, What Type?:

If Cancer, What Stage:

Date of Last Treatment:

Being Treated for Hypertension or High Cholesterol:

Diabetes?:

Treatment Type:

Age of Onset:

Parents or Siblings Die of Cancer/Heart/CAD before 65?:

Family History Details:

Name all Prescription Medications Taken in the Last 12 months and what for:

Additional Insured

Additional Insured Name:

Add. Insured DOB:

Add. Insured Gender:

Add. Insured Height (inches):

Add. Insured Weight:

Add. Insured Tobacco User?:

Add. Insured Types of Tobacco:

Add. Insured If Stopped, When?:

Add. Insured Heart/CAD History:

Add. Insured Heart/CAD Details:

Add. Insured If Cancer, What Type?:

Add. Insured What Cancer Stage?:

Add. Insured Date of Last Cancer Treatment:

Add. Insured Treated for Hypertension or High Cholesterol?:

Add. Insured Diabetes?:

Add. Insured Treatment Type:

Age of Onset:

Add. Insured Parents or Siblings Die of Cancer/Heart/CAD before 65?:

Add. Insured Family History Details:

Add. Insured Medications Taken in Last 12 Months:

Policy Information

Death Benefit Applied For: *

Type of Plan Applied For (if term, how long): *

Requested Riders:

Preferred Carrier:

Or Simply Enter "Best Available"

Replacing Existing Coverage?: *

Replacing How Much:

Previous Premium Being Replaced:

Additional Comments or Notes:

Please include any recent ( Last 5 years ) moving violations as well as any high-risk avocations (aviation, sky-diving, SCUBA, etc.)

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