Life Insurance — Quick Quote Intake

Complete the basics below for a quick quote estimate. Fields marked required help speed things up.

First Name *

Last Name *

Email *

Phone *

Age *

Gender *

Amount of Coverage ($) *

Product Type *

Term Whole Life Unsure

Nicotine Use (last 12 months)? *

No Yes Occasional / Vaping

Premium Payment Frequency *

Client’s Underwriting Class *

Preferred Plus Preferred Standard Unsure

Preferred Plus: Excellent health & lifestyle, no tobacco, favorable labs/history.
Preferred: Very good health; well-controlled minor conditions; favorable build/history.
Standard: Average health/build with typical risk factors; baseline rates.

Add coverage for children (up to age 25)? *

No Yes

Notes (medical history, prescriptions, hobbies, coverage goals, riders, budget, etc.)

This intake form is for preliminary quoting only and does not guarantee eligibility, rate, or coverage. Final approval and pricing are determined by the carrier’s full underwriting review.