Fields labeled with an * are REQUIRED
Agent Name *
Agent Email *
Agent Phone *
Fill out the form below as completely as possible.
We will prepare your quote, based on the information you provide.
CLICK HERE to download a Fact Finder form to help you gather important information.
CLICK HERE to download a Generic Underwriting Reference, to quickly help you determine rate class.
If you experience any problems, please contact us at (888) 539-1633. All personal information is protected by HIPAA regulations.
Purpose for Coverage: *
Full Underwriting or Simplified Issue? * Full UnderwritingSimplified Issue
Coverage Type: * —Please choose an option—TermAnnual Renewable TermULVULIULWLSingle Premium WL
Term —Please choose an option—10 Year15 Year20 Year25 Year30 Year
Survivorship: —Please choose an option—SULSVULSWL
Rate Class * —Please choose an option—Best RatePreferredStandardRatedNot Sure
Rated Level (if applicable)
Coverage Amount *
Client budget per month for this plan $:
Full Name *
Phone *
Email *
State * —Please choose an option—AKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVIVAWAWVWIWY
Gender * —Please choose an option—FemaleMale
Date of Birth *
Age *
Current Nicotine Use * —Please choose an option—NoneCigarettesCigarsPipeDipChewNicotine GumECigOther
Describe if "Other"
Quantity per month
Former tobacco use: (List each type of tobacco, quantity and frequency used, and date of last use)
Height *
ft.
in.
Weight *
lb.
Family history is a consideration for each rate class
To your knowledge, is there any family history (parent or siblings) with onset of disease prior to age 60 due to:
Cardiovascular disease
Cerebrovascular disease
Diabetes
Cancer
Please answer YES or NO. *
—Please choose an option—YesNo
If YES, please provide full details with impairment, age at onset and age at death if deceased:
Father:
Mother:
Siblings:
Latest BP reading:
Latest total cholesterol (mg):
Latest cholesterol/HDL ratio:
Are you taking medication for blood pressure?....—Please choose an option—YESNO
Name of medication
Are you taking medication to lower cholesterol?...—Please choose an option—YESNO
NoneFlyingRacingSky DivingScuba DivingOther (describe below)
Description:
US Citizen? * —Please choose an option—YESNO
If no, provide type and expiration date of visa, green card status, and length of time in the USA:
Any future plans to live or travel outside the USA?
—Please choose an option—YESNO
If yes, provide purpose, cities, countries, frequency, and duration:
Have you had any of these motor-vehicle-related incidents in the past 10 years?
—Please choose an option—NoneMoving ViolationReckless DrivingDWI or DUILicense SuspensionLicense Revoked
Provide dates & details:
Have you ever had, been told you had, or been treated for any of the conditions listed? If yes, check the box and explain each:
Alcohol Abuse
Alzheimer's/dementia/cognitive impairment
Asthma
Cirrhosis
COPD
Coronary artery or cerebrovascular disease
Crohn's Disease
Depression/anxiety
Drug Abuse
Epilepsy
Heart Murmur/Valve Disease
Hepatitis
Irregular Heartbeat/Palpitations
Kidney Disease
Lupus
Multiple Sclerosis
Peripheral Vascular Disease
Rheumatoid Arthritis
Sleep Apnea
Stroke
Other
List dates, diagnosis, details & treatments. Also enter names, addresses, and phone numbers of all consulted physicians.
(refer to Common Medical and Non-Medical Impairment for critical underwriting factors):
Please verify that all the information you have entered is correct, then click Submit
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By clicking and submitting this form with my name, phone number, and e-mail address, I agree that I am at least 18 years of age. By clicking and submitting this form, I understand that I am enrolling in an ongoing marketing campaign about insurance services and other options from Empower Brokerage or a licensed agent, and I will receive phone calls and e-mails (even if that phone number is on any Do Not Call Registry or is a mobile number). If you want to opt out of receiving future e-mails from Empower Brokerage, you can do so at any time by clicking the “unsubscribe” button in our e-mail. For more details, see our Privacy Policy.
