Customer Name #1*
First Name Last Name
Customer Name #2 ( If only One Applicant Please fill in N/A)*
First Name Last Name
Estimated TOTAL Household Loans - Example: Auto Loans, Credit Cards, Mortgage Loan, Student Loan, etc...*
Annual Income Customer #1*
Multiply annual income x 5 if married or there are 2 incomes in household. Multiply x 10 if married and 1 income household or single.
Annual Income Customer #2 ( If only One Applicant Please fill in N/A)*
Multiply annual income x 5 if married or there are 2 incomes in household. Multiply x 10 if married and 1 income household or single.
Final Expenses Insured #1*
Include a minimum of $15,000
Final Expenses Insured #2 ( If only One Applicant Please fill in N/A)*
Include a minimum of $15,000
Education (# of children X $100k)*
Included $100k per Child or Zero if No dependents under 19.
Total Need Insured #1
Add - Total Household Loans, Annual Income, Final Expenses, and Education.
Total Need Insured #2 ( If only One Applicant Please fill in N/A)
Add - Total Household Loans, Annual Income, Final Expenses, and Education.
Current Coverage - Customer #1*
Do you currently have life insurance in place? If yes, how much? Where?
Current Coverage - Customer #2 ( If only One Applicant Please fill in N/A)*
Do you currently have life insurance in place? If yes, how much?
The next step in determining what rate you qualify for is filling out a two-page medical questionnaire. Then we will schedule a time for our paramed-examine to check your blood pressure and cholesterol levels which is completely free. Once our underwriters get your medical information they let us know what rate you qualify for. Then we get back together to figure out what kind of policy fits your budget and is right for your family.
Sign - Customer #1
Clear
Date - Customer #1
Month Day Year
Date
Sign - Customer #2
Clear
Date - Customer #2
Month Day Year
Date
Should be Empty: