Critical Insurance Quote Request
Agent Information:

Agent name:

Phone number:

E-mail:


Client Information (basic):

Client name (important):

Client date of birth or age:

Client gender:

Client resident state:


Client Information (health history):

Client's build?

Has your client use tobacco products in the last 12 months?

What Rate Class should this client be quoted?

Has your client's parents or siblings been diagnosed with a critical illness? 

- if yes, what was the diagnosis?

- How old were they at diagnosis?

Please list any health conditions, medications, dosages and/or hospitalizations in the past 10 years:







Client Information (occupation):

Client's employment status?

Client's occupation?

Client's annual income?


Illustration (Quote) Design:

Desired Face Amount that you want quoted? 

- Alternative Face Amounts?

What is your client's current monthly rent or mortgage payment?

Approximately how much debt does your client have at current?

How much money does your client put into retirement each year?

Would you like a Life Insurance or Disability Income quote as well for your client? 

- If so, what would you like to see quoted:




You're almost done!  Once you have answered the required questions above, click the "Submit Form" button to send us your request.  We will email your quote shortly!







MaleFemale
W-2Self-Employed
YesNo
if unsure, if your client overweight?
StandardTable 1Table 2Table 3Table 4
YesNo
YesNo
YesNo