Our Free Quote Service is designed to allow you the consumer to obtain quick replies on the various types of plans available and their cost. The following form is designed to encompass all of the various products and services we offer. Please go through the form and check off any of the types of insurance or retirement plans you have an interest in. Once we receive this information it will be processed immediately.

PERSONAL INFORMATION:

Name


DOB (02-04-80)


Gender (male / female)


Smoker (yes / no)


E-mail address


Phone (xxx-xxx-xxxx)


City


State


Zip


Health Status (Preferred / Standard / Sub Standard)


Retired (yes / no - year retired)


Types of Available Quotes

RETIREMENT PLANS:
Quote will include tax deferred fixed annuities and equity indexed annuities with current interest rates, up front bonuses, terms for rate guarantee, etc.



Qualified Money (pre-tax dollar in account (yes / no))


Type of account: (401k / IRA / 403b / 457 / other)


Account value: ($)


Is this a rollover? (yes / no)


Will you continue making deposits into the new account? (yes / no)


Non qualified money: (yes / no)


Account value: ($)


Will you continue making deposits into the new account? (yes / no)


Are you looking to start an immediate payout on the money with a lifetime income guarantee?
(yes / no)

LIFE INSURANCE:

Term Insurance (yes / no)


Universal Life Insurance (yes / no)


Whole Life Insurance (yes / no)


Face Amount ($)


Is there an initial deposit going into the account from an existing policy? If so how much? ($)

DISABILITY INSURANCE:


Monthly income benefit you are looking for? ($)


Type of Employment:

LONG TERM CARE INSURANCE:


Is this on a single life or spouse included: (single / spouse)


Age of spouse:

MORTGAGE INSURANCE:

Amount of existing 1st


Years remaining on the 1st mortgage:


Gender / age of the person(s) on the policy: (Female 36 / Male 40)


Current monthly payment on 1st mortgage ($):


Amount of existing 2nd


Years remaining on the 2nd mortgage:


Gender / age of the person(s) on the policy: (Female 36 / Male 40)


Current monthly payment on 2nd mortgage ($):