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Finding the Right Insurance

* indicates a required field. While not all fields are required, the more complete the information you provide, the more accurate the quotes and illustrations we can provide, and the better the advice that we will be able to give you. Let me start by saying we can get you life insurance in almost any situation. What we don't want is to seemingly be "baiting and switching" you. The following information is not a complete application, but it does hit the major points for most people.  Once you submit this form, your agent will be in touch with you.

General information

Why are you interested in life insurance?

Is it ok to text you at ths number?
Are you married?
Will you be the one insured?
Is the Proposed Insured . . .
Is the proposed insured married?

Health Information

Please answer the questions in this section on behalf of the insured.

Do you use tobacco products?

Please list any medications that you have been prescribed in the last 5 years and the reason for which it was prescribed. If the reason is still a current medical condition, please indicate how long ago (number of years-don't need an exact date, just an estimate) you were diagnosed.  You may exclude over -the-counter (OTC) purchases as well as short-term prescriptions such as antibiotics that were prescribed for a temporary illness that has passed.  If you take more than one, do not worry; another field will appear as needed as you enter your medications (maximum of 10 fields).

Do you have any medical condtions that have been diagnosed for which you are NOT taking medication?
Do you use any medical devices? Examples include: Pacemaker, Defibrillator, Neurotransmitter, Oxygen and CPAP machines
Have you ever had a heart attack, stroke, cardiomyopathy, aneurysm, cancer, liver/kidney disease, cirrhosis?
If you suffer from diabetes, have you had any of the following complications? Neuropathy, diabetic retinopathy, diabetic coma, isulin shock, or amputation.
Have you in the last five years; or are you planning to do, any of the following? Take flying lessons, scuba diving, bungee jumping, hang gliding, rock climbing, or sky divng.

Financial Information

Do you or your spouse own a business?
Do you own your home?
Do you own a second home or spend significant time in a second sate?
Do you make bi-weekly payments or otherwise pay extra on the mortgage?
Do you have any investment vehicles for retirement or anything else that "acts like" life insurance? (Check all that apply)

Success! Your agent will contact you within one to two business days. If you are not working with an agent, we will assign one to you. In the mean time, feel free to reach out to us with any questions. You can reach us by phone or text at (208) 447-7200.

Do you have a last will and testament in place?
Do you have a family trust?
Do you currently have life insurance?
In addition to life insurance, would you be interested in learning more about any of the following products? (Check all that apply)
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