Life Insurance Quote Worksheet

1.About You

Name

Date of birth

Age

Phone

State

2.What do you want your life insurance to accomplish?

Other

Who would you primarily want this insurance to protect?

What financial concern would you most want the insurance to address?

4.Coverage you would like to learn about

Final Expense — primarily for funeral and final expensesTerm Life — coverage for a selected periodUniversal Life — permanent coverage, subject to policy terms and fundingIndexed Universal Life (IUL) — permanent coverage with index-linked cash valueParticipating Whole Life — permanent coverage with cash value and possible dividendsI'm not sure — I'd like to compare the options

5.Current life insurance

I do not currently have life insuranceI currently have life insurance

Carrier

Type

Coverage amount

Premium

What would you like to do with existing coverage?

KeepAdd coverageReview options

6.Current medications

List current medications, dosage, and what each is taken for

Enter each medication on its own line, or separate them with commas. Include dosage and what it treats (for example: Lisinopril 10mg — blood pressure).

8.What would you like us to help you accomplish?

Anything else you'd like us to know about your goals?

By completing this form, you give us permission to contact you by phone, text, or email regarding life insurance options. This is a solicitation for insurance. The information provided will help us review options based on your goals, budget, and information provided.

Life Insurance Information Worksheet

1.About You

2.What do you want your life insurance to accomplish?

3.Coverage & Budget

4.Coverage you would like to learn about

5.Current life insurance

6.Current medications

7.Health history

8.What would you like us to help you accomplish?

9.Schedule your life insurance review