Crystal Clear Insurance Coverage Quote Request

Insurance Protection Form

For free coverage quote & consultation
Name*

First NameLast Name
Email*
example@example.com
Phone *
Please enter a valid phone number.
Please select coverage quote type (list all that apply)

Living BenefitsSmall BusinessMortgage ProtectionTrust CoverageIndex Universal (IUL)RetirementChildren's CoverageI'm not sure which coverageFinal Expense/Burial CoverageI have questions about coverage optionsOther
Who would you like quotes for?*

SelfSpouse/Additional AdultChildren under 18
Status:*

SingleMarriedEngaged
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Of Birth*

MonthDayYear
Date
Current Age*
Gender*

MaleFemale
Have you ever tested positive for Covid19*

YesNo
In the event that you pass away, what would you like insurance coverage to pay? (list all that apply)*

Pay my funeral and burialPay my final expensesPay my mortgage paymentsPay off my entire house/mortgageLeave my family/spouse/children extra moneyAll of the aboveOther
Do you have children under 18 yrs old?*

YesNo
How many children do you have under age 18? *
Age of each child (type all that apply)*
Ex: 6,9,13
Your Height*
Your Weight*
Do you currently use tobacco products?*

YesNo
Have you used tobacco products in the past 12 months?*

YesNo
Have you ever been diagnosed with any health conditions? (diabetes 1 or 2, high blood pressure, heart, kidney, stroke, cancer, asthma, seizures etc..)*

YesNo
List the names of current prescribed medications w/ conditions used for. (N/A for none)*
Ex: Metformin for diabetes, Lisinopril for hypertension, High Blood Pressure (If you don't remember name of medicine just list what condition its for)
Monthly or annual income (to replace in case of loss)*
Ex: $3,000 per month/ $36,000 per year
Do you Currently Rent or Own your home? *
Monthly Rent/Mortgage payment? *
What is pay off amount on Mortgage? (Estimate)*
Ex: $100k, $150k, etc..
What is length of Mortgage?
Have you ever been convicted of a felony?*
Has your drivers license been suspended in the last 3 years? *
How many traffic ticket/moving violations have you received in last 5 years?*
When are you usually available/free if we need to reach you for additional information?

I am available on      from    Time  to   Time
Any additional questions you would like answered in free customized quote?
Ex: What do I qualify for? How long does it take for coverage to start? Can I get coverage on my spouse/children/parent?
Spouse / Additional Adult Form

Complete for free quote/consultation for Spouse/Adult Child/Parent/Etc.. Press "Save" button to complete later.
Spouse/Additional Adult Name

First NameLast Name
Gender (Spouse/Additional Adult)

MaleFemale
Date Of Birth*

MonthDayYear
Date
Current Age (Spouse/Additional Adult)
Height (Spouse/Additional Adult)
Weight (Spouse/Additional Adult)
Has (Spouse/Additional Adult)ever been diagnosed with any health conditions? (diabetes 1 or 2, high blood pressure, heart, kidney, stroke, cancer, asthma, seizures etc..)

YesNo
List the names of (Spouse/Additional Adult) current prescribed medications w/ conditions used for. (N/A for none)
Ex: Metformin for diabetes, Lisinopril for hypertension, High Blood Pressure (If you don't remember name of medicine just list what condition its for)
Has (Spouse/Additional Adult) drivers license been suspended in the last 3 years?
Has (Spouse/Additional Adult) ever been convicted of a felony? .
Should be Empty:

Insurance Protection Form

Spouse / Additional Adult Form