Thank you for taking the time to fill this quoting form for life insurance and/or supplemental insurance. Take your time and share with us as much as possible so we can create the ideal plan for you.
Please rest assured that all the information you provided will be treated with the utmost confidentiality. Your privacy is important to us.
General information
Name
Last name
Date of birth (mm/dd/yyyy)
Height (in cms or feet)
cms
Feet
Weight (in pounds or kilos)
Pounds
Kilos
Smoker - Yes or No
No
Yes
City
Phone number
Email
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Please rest assured that all the information you provided will be treated with the utmost confidentiality. Your privacy is important to us.
Do you have personal life insurance?
No
Yes
What kind of protection?
A
Term
B
Whole Life
C
Critical Illness
D
Disability
Amount of the coverage
Approximate debt for:
If relevant, choose one option below
Mortgage
Student loans
Line of credit
Significant debt
Approximate monthly income
Do you have group benefits at work?
No
Yes
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If you would like us to quote for for family plans, please answer a few more questions, you'll save 27% with family plans.
Spouse's first name and last name
Spouse's date of birth (mm/dd/yyyy)
Spouse's height and weight, if known
cms
Feet
Pounds
Kilos
Kids' name(s)
Kids' Date of birth (mm/dd/yyyy)
Kids' height and weight, if known
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Important health questions to see what kind of plans you qualify for:
Have you or a family member (kids or spouse) had or received any medical advice or treatment within the last 5 years for the following:
Heart attack, angina, atrial fibrillation, congestive heart failure, coronary artery disease that required bypass surgery, a stent or angioplasty, or a heart valve replacement?
No
Yes
Stroke, transient ischemic attack (TIA)?
No
Yes
Cancer, melanoma, Hodgkin's disease or leukemia?
No
Yes
Multiple Sclerosis, cystic fibrosis, muscular dystrophy or Down's syndrome?
No
Yes
Alcoholism or drug addiction?
No
Yes
Diabetes which requires insulin, or diabetes which was diagnosed prior to age 40?
No
Yes
HIV or AIDS?
No
Yes
Additional information you would like to let us know?
I have authorized and consented to the collection, use and disclosure of my personal information for the purpose of quoting for a life insurance and/or living benefits plans to Alika Martin.
I consent to receive communications from Alika Martin via e-mail, phone and SMS, WhatsApp.
We keep in confidence personal information about you and the products and services you have with us.
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