Second-to-Die Life Quote Request

Please fill out the following form to obtain a quote on a Second-to-Die life insurance policy. Once we receive this quote request, we will send you an application appropriate for the coverage you requested. A Second-to-Die life insurance policy covers two insured individuals at the same time and the benefit is paid upon the second death. In general, this type of policy is used to pay estate taxes when due. Remember, this form is not an application for insurance.

Any information provided on this for is held strictly confidential and will only be used for developing a quote for you.

* Required Field

Client Information

Last Name

First Name

Middle Initial

Spouseís Name

Last

First

Middle

   

Mailing address 

Street

City

State

Zip

Telephone Number

Alternate Telephone Number

E-mail Address

Fax Number

 

Quote Information

Desired Benefit Amount?

Benefit Amount

Client

Spouse

Birthdate?

Gender?

Male

Female

Male

Female

Height? (example 5��")

    Inches
   Inches

Weight?

lbs.

lbs.

Smoke or Tobacco use?

Have either been treated for cancer, diabetes, or cardiovascular disorders in your life?

Yes No
Yes No

If yes, please describe

Have parents or siblings been treated for cancer, diabetes, or cardiovascular disorders prior to Age 60?

Yes No
Yes No

If yes, please describe

Are you taking any medication?

Yes No
Yes No

If yes, please give dosage and frequency

Explain any health problems that you think would impact the rate.

Have you had 2 or more moving violations in the last 2 years or any DUIís in the last 5 years?

Yes No
Yes No

If yes, please describe.

What is the amount of Current Life Insurance?

What are your current Life Insurance Companies?

What is your current monthly life premium?

 

Comments or Questions

 

Producer Information

Producer Name *

Producer Email *

Producer Phone *

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