Florida Life Insurance and more: Life Insurance Request Form

When thinking about life insurance use the D.I.M.E method: Debt, Income replacement, Mortgage and Education expenses. Click Here for calculation

Coverage Type
Choose between Term, Universal Life, Indexed Universal Life and Whole Life.
Please click the submit button to request your quote for Life Insurance. This is for quoting purposes only. Never cancel existing coverage until new coverage is signed for and effective. Thank you.
Email
pm
am
Best Time to Call
Phone
Zip
State
City
Your Name
Who is to be Covered?
Your Gender?
Your Birthdate?
Tobacco Products?
No
Yes
Height?
ft
inches
Weight?
Weight?
inches
ft
Height?
Yes
No
Tobacco Products?
Your Birthdate?
Spouse Gender?
Child Gender
Child DOB
Child 2 DOB
Child 2 Gender
Child 3 Gender
Child 3 DOB
Child 3 DOB
Child 3 Gender
Child 3 Gender
Child 3 DOB
Add your children to your policy $10,000 policy on each child.
Your Coverage Amount
Have you ever been rated or declined life insurance?
If Yes Please Explain:
Have you ever been treated for high blood pressure or cholesterol?
Any Medications?
If Yes Please Explain:
Have you had any of the following conditions?
High Blood Pressure
Diabetes
Cancer
Heart
Coverage Amount
Coverage Type
You
Spouse
Please let us know of any special circumstances or medical conditions
Are you willing to take a paramed exam? No paramed required for amounts up to $300,000
General Information
Medical Background
Customize Your Coverage
Customize Your Quote

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Term: Just as it is, insurance that lasts a specified amount of time. A lot of insurance for the least amount of cost. $

Universal Life: Combines the low-cost protection of term insurance with a savings component that is invested in a tax-deferred account, the cash value of which may be available for a loan to the policyholder. $$

Whole Life: Provides coverage for an individual's whole life, rather than a specified term. A savings component, called cash value or loan value, builds over time and can be used for wealth accumulation. $$$

Indexed Life: Indexed Universal Life is flexible-premium adjustable life insurance that combines the death-benefit guarantees of life insurance with the opportunity to build cash values that are linked to the growth of a stock-market index but do not involve the risk of market loss. $$$$

 

 

 

 

Paramed exams keep premiums low. Companies that do paramed exams generally have lower premiums

 

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