Second-to-Die Life Quote Request

Please fill out the following form to obtain a quote on a Second-to-Die life insurance policy. Once we receive this quote request, we will send you an application appropriate for the coverage you requested. A Second-to-Die life insurance policy covers two insured individuals at the same time and the benefit is paid upon the second death. In general, this type of policy is used to pay estate taxes when due. Remember, this form is not an application for insurance.

Any information provided on this for is held strictly confidential and will only be used for developing a quote for you.

Personal Information

Your Name

Last

First

Middle

Spouseís Name

Last

First

Middle

   

Mailing address 

Street

City

State

Zip

Telephone Number

Alternate Telephone Number

E-mail Address

Fax Number

 

Quote Information

What Benefit Amount do you want?

Benefit Amount

Self

Spouse

What is your birthdate?

What is your gender?

Male

Female

Male

Female

What is your height? Height (example 5' 4")

    Inches
   Inches

What is your weight?

lbs.

lbs.

Do you smoke or use tobacco?

Have you ever been treated for cancer, diabetes, or cardiovascular disorders in your life?

Yes No
Yes No

If yes, please describe

Have parents or siblings been treated for cancer, diabetes, or cardiovascular disorders prior to Age 60?

Yes No
Yes No

If yes, please describe

Are you taking any medication?

Yes No
Yes No

If yes, please give dosage and frequency

Explain any health problems that you think would impact the rate.

Have you had 2 or more moving violations in the last 2 years or any DUIís in the last 5 years?

Yes No
Yes No

If yes, please describe.

What is the amount of Current Life Insurance?

What are your current Life Insurance Companies?

What is your current monthly life premium?

 

Comments or Questions

 

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Securities and Advisory services offered through LPL Financial. A registered investment advisor. Member FINRA & SIPC.

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Insurance License in the following states: CA, FL, OH