Life Insurance Proposal Request
This is a solicitation for life insurance. An agent will contact you by phone and email.
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Date of Birth
Do you smoke, or use any other form of tobacco or nicotine? Please check all that apply.
Never smoked or used nicotine
Used to smoke, but quit more than 12 months ago
Cigar or pipe smoker
Smokeless tobacco - chew, snuff, dip
E-cigarette user (vaping)
Nicotine patch or gum user
Marijuana user (includes edibles and vaping)
Do you have any pre-existing health conditions?
How much coverage do you need? If you are unsure or want an analysis, please let us know in your answer and we can help you make an informed decision.
What kind of life insurance do you need? If you are unsure, please let us know in your answer and we can help you make an informed decision.
Please indicate what life insurance strategy you are interested in by checking the boxes. You may check more than one.
Personal Protection - Income Replacement, Debt Coverage, and Final Expenses
Business Protection - Business Debts, SBA 7(a) Loans, etc.
Key Person Life Insurance
Buy/Sell Agreement Funding Life Insurance
Group Term Life Insurance
Group Term Carve-Out Life Insurance
Executive Benefits funded with Life Insurance
Life Insurance Retirement Plan (LIRP)
Section 7702 Plan
Corporate Owned Life Insurance (COLI)
Trust Owned Life Insurance (TOLI)
Bank Owned Life Insurance (BOLI)
Charitable Gifting using Life Insurance
Charitable Remainder Trust replacement Life Insurance
Pension Life Insurance
High Early Cash Value Life Insurance to minimize Charge to Earnings issues
Dividend Paying Whole Life Insurance for Personal Banking
Indexed Universal Life Insurance for Tax Free Retirement
Dividend Paying Whole Life Insuance for Tax Free Retirement
Lifetime Level Term Life Insurance (Guaranteed Universal Life)
Section 162 Executive Bonus Plan Life Insurance
Split Dollar Life Insurance
Nonqualified Deferred Compensation funded with Life Insurance
Life Insurance with Long Term Care benefits
Life Insurance with benefits for Critical Illness and Chronic Illness
Life Insurance required for SBA Loans (Small Business Administration)
Pension Maximization Life Insurance
Social Security Optimization Life Insurance
RMD to Tax Free Life Insurance (Required Minimum Distribution)
Premium Finance Life Insurance
Section 1035 Tax Free Exchange Life Insurance
Annuity Alternative Life Insurance (Modified Endowment Contract or MEC)
457(f) Deferred Compensation Life Insurance
412(e)(3) Fully Insured Defined Benefit Pension Plan Life Insurance
Section 79 Plan Life Insurance
Do you have any other interests? Please indicate by checking the boxes.
I need help with my Life Insurance
I need help with my Disability Insurance
I need help with my Long Term Care Insurance
I need help with my Retirement Planning
I need help with my Estate Planning
I own a business and need help with my Business Planning
I own a business and want to set up a 401(k) Plan
I own a business and need help with my Employee Benefits
I want to protect my retirement savings from the next stock market crash
I want a retirement income that is guaranteed to last my lifetime
I want to double my retirement income over the next ten years
I need more tax deductions
Please be sure to click the submit button!
This is a solicitation for life insurance and financial services. A life insurance agent will contact you by phone and email. Thank you!
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