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
Alternate Telephone Number
Desired Benefit Amount?
Height? (example 5")
Smoke or Tobacco use?
Have either been treated for cancer, diabetes, or cardiovascular disorders in your life?
If yes, please describe
Have parents or siblings been treated for cancer, diabetes, or cardiovascular disorders prior to Age 60?
Are you taking any medication?
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?
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 Name *
Producer Email *
Producer Phone *
7131 Spring Meadows Dr. West Suite FHolland, OH 43528Tel: (419) 491-0090Fax: (419) 491-0083Email: firstname.lastname@example.org
Securities and advisory services offered through LPL Financial, a registered investment advisor, member FINRA/SIPC.Licensed to do business in: CA, IL, IN, MI, NC, OH, OR, PA, NM, FL, GA