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Life Insurance Quote Request
Broker Information
Agent Name
*
First
Last
Email
*
Business Phone
*
Client Information
Applicant's Name
First
Last
Applicant's Date of Birth
*
MM slash DD slash YYYY
Applicant's Sex
*
Female
Male
State
*
Height
Weight
Does your client use tobacco or vape?
Yes
No
Type of tobacco
*
Cigarette
Cigar
Chew or Snuff
Vape
Nicotine Patch
Pipe
Marijuana use?
Yes
No
Frequency and type of marijuana use
*
Have you ever been declined for life insurance?
*
Yes
No
Unknown
Reason(s) for Decline and Carrier who declined them?
DUI or DWI in the last 5 years?
*
Yes
No
Not sure
Dates and Details of the DUI/DWI
Have you ever filed bankruptcy
*
Yes
No
Not sure
Dates and Details of Bankruptcy. Type of BK and is it discharged?
Have you ever been treated or diagnosed with?
*
Anxiety / Depression
Cancer
Crohn's Disease
Diabetes
Heart Attack / Coronary Artery Disease
Heart Murmur / Atrial Fibrillation
Sleep Apnea
Stroke / TIA
Other - Anything that could affect Mortality
None of the above - Confirmed with Field Underwriting
If yes to any of these conditions, please complete a the specific quick quote form(s) at https://rbrokers.com/tools/quick-quote-questionnaires/
Quick Quote Questionnaires
Do you participate in any of the activities below?
*
Aviation - Private Pilot
Auto Racing
Motor Cycle Racing
Mountain Climbing
Scuba Diving
Sky Diving
None of the above
If yes to any of these avocations, please complete a the specific quick quote form(s) at https://rbrokers.com/tools/quick-quote-questionnaires/
Quick Quote Questionnaires
List current medications
Rate Classification you would like to show
Preferred Best Non-Tobacco
Preferred Non-Tobacco
Standard Plus Non-Tobacco
Standard Non-Tobacco
Preferred Cigarette Smoker
Preferred Tobacco-Chew, Cigar, Pipe
Standard Tobacco-Cigarette Smoker
Standard Tobacco-Chew, Cigar, Pipe
Requested rate class is dependent on the answers to the previous field underwriting questions.
Quote Information
Face amount(s)
*
State of Sale
Desired Premium or Budget, if known
Primary objective
Death Benefit
Cash Accumulation
Retirement Income
Other objectives / needs
Key Man
Family Protection
Buy Sell
Loan / Debt Repayment
Other
If "Other' please explain:
Specified carrier
Product Information
Plan Type
Term
Guaranteed No-Lapse Universal Life
Index UL
Survivorship UL
Variable UL
Whole Life
Final Expense
Spouses Name
First
Last
Date of Birth of Joint Insured
MM slash DD slash YYYY
Spouses / Joint Insured Health Information
Go through the same field UW questions so we can best ascertain potential rate class.
Term Length
10 Year Term
15 year Term
20 year Term
25 year Term
30 year Term
31+ year Term
Payment Duration for Permanent Insurance
Pay Premiums For Lifetime
10 Pay
20 Pay
Pay To Age 65
Other Short Pay Scenario
"Other Short Pay Scenario" Desired
Payment Mode
Annual
Semi-Annual
Quarterly
Monthly
Additional Premiums
1035 Exchange
Lump Sum
Death Benefit Option
Level
Increasing
Riders
Select Riders
Long Term Care Rider
Chronic Illness Rider
Waiver of Premium
Return of Premium Rider
Child Rider
Accidental Death Rider
Critical Illness Rider-i.e. Cancer, Stroke, etc.
Disability Income Rider
Case Information
Additional comments or health concerns?
