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 form is held strictly confidential and will only be used for developing a quote for you.

Personal Information

Your Name

First NameMiddle NameLast Name

Spouse's Name

First NameMiddle NameLast Name

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone

Area CodePhone Number

Work Phone

Area CodePhone Number

What is the best time to contact you?

Fax Number

Area CodePhone Number

E-mail Address

Quote Information

Self

What benefit amount do you want?

Birth Date

MonthDayYear

Gender

Height

Weight

Do you smoke or use tobacco?

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

If yes, please describe

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

If yes, please describe

Are you taking any medication?

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 DUI's in the last 5 years?

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?

Spouse

What Benefit Amount do you want?

Birth Date

MonthDayYear

Gender

Height

Weight

Do you smoke or use tobacco?

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

If yes, please describe

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

If yes, please describe

Are you taking any medication?

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 DUI's in the last 5 years?

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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