Quotes

Need a quote? Complete our request form below and we'll prepare an illustration for you.

You may also run your own quotes using WinFlex Web.

Permanent Life Quote Request Fields marked with * are required
Producer:
* Agent Name:
* Address:
* City:
* State:
* Zip:
* Email Address:
* Phone #:
* Fax #:
Agent / Dealer:
Return Method:	Fax Mail Agent Pick-up Email
Client:
Insured #1
Name:
Birthdate:
Gender:	Male Female
Health Class:	Preferred Standard
Tobacco Use:	Pipe Cigar Chewing
Cigarettes:	(If quit, last used: )
Medical Problems:
Medications & Dosage:
Insured #2
Name:
Birthdate:
Gender:	Male Female
Health Class:	Preferred Standard
Tobacco Use:	Pipe Cigar Chewing
Cigarettes:	(If quit, last used: )
Medical Problems:
Medications & Dosage:
Illustration:
Primary Objective:
Death Benefit Cash Accumulation Guarantees Low Premium
Face Amount(s):
Specified Carrier:
Product Type:
Universal Life Whole Life Whole Life Blend % Term Variable Survivorship Other
Term: ART 5 10 15 20 30 Other
Super-Preferred? If so, HT: WT:
Payment Plan:
Level -Pay -Pay To Age
1035 Rollover: Other Dump-In:
Cash Value Target:
Endow
Alternative Amount: at Maturity or Age
Interest/Div. Rate: Current Other: %
Payment Mode:
Annual Semi-Annual Quarterly Monthly
State of Issue:
State in which insurance is to be issued -
Riders:
Term Rider - Insured Amount: To Age: Term Rider - Other
Name:
Birthdate:
Amount:
To Age:
Waiver of Premium
Child Insurance Rider:
ADB:
Other:
Mail, Phone and Fax (If other than Agent Information):
Special Instructions:
Supplies:
Appointment Forms Application Packs Product Information
Your request cannot be honored unless this form is completed.