Quote Request Form Please select what type of custom quote you would like us to provide. (* denotes required) Select Type of Quote:[Select Quote]Life InsuranceLong Term Care InsuranceDisability Insurance401(k) Information RequestGeneral Information RequestPersonal InformationName* First Last Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email Date of Birth: Date Format: MM slash DD slash YYYY Gender:MaleFemaleHeight:Weight:Life Insurance Policy InformationSelect desired Death Benefit:<Please Select>$100,000$125,000$150,000$175,000$200,000$250,000$300,000$400,000$500,000$750,000$1,000,000$2,000,000$3,000,000$5,000,000More than $5,000,000What type of policy are you looking for?<Select Type>Annual Renewable TermLevel TermWhole LifeUniversal LifeSecond-to-DieNot SureHow long do you want the policy to be in effect?<Please Select>10 or more years15 or more years20 or more years25 or more years30 or more yearsMy Whole LifeTell Us About Your WorkWhat is your Occupation?Describe your daily duties:Do you own a business?YesNoEstimate Your Current Monthly Income:Is Disability Insurance part of your benefit package?YesNoDisability Policy InformationDisability insurance helps replace income lost because of an accident or illness. One survey found that 43% of people aged 40 will suffer a disability of at least 90 days before they reach age 65. – 2000 Field Guide, National UnderwriterHow much of your income do you want disability insurance to replace?[Select]40%50%60%70%If you become disabled, what's your desired waiting period before benefits begin?[Select]30 days60 days90 days180 daysIf you become disabled, how long do you want to be eligible for benefits?[Select]2 years5 years10 yearsUnil 65Long-Term Care Policy InformationOne of the greatest potential risks faced by America’s elderly is the need for long-term care. Long-term care insurance transfers a portion of the risk of long-term care expenses to an insurance company helping to protect you and your family from potentially devastating expenses.What daily benefit would you like your long-term care policy to provide?[Select]$50$60$70$80$90$100$110$120$130$140$150$160$170$180$190$200$210$220$230$240$250$260$270$280$290$300$310$320$330$340$350$400$450$500If you need long-term care, what's your desired waiting period before benefits begin?[Select]0-30 days31-100 days101-365 daysIf you need long-term care, how long do you want to be eligible for benefits?Lifetime3 Years or More12 to 35 monthsDo you want your policy to include home-health care coverage?[Select]YesNoDo you want your policy to have the option to increase with inflation?[Select]YesNoBriefly describe any medical events in the past 10 years that have required hospitalization or surgery:Would you like to include a spouse?*YesNoSpousal InformationName* First Last Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email Date of Birth: Date Format: MM slash DD slash YYYY Gender:MaleFemaleHeight:Weight:Spousal Long-Term Care Policy InformationAdditional InformationAre you a tobacco user?YesNoAre you a pilot?YesNoHow would you describe your current health?ExcellentVery GoodGoodPoorAny additional information we should consider while processing your request?401(k) Plan InformationThe most common employer-sponsored retirement plan is the 401(k) plan. The 401(k) plan is a defined contribution plan. It allows employees to make pre-tax contributions, and the funds contributed plus any earnings accumulate tax deferred.When would you plan on implementing your new 401(k) plan?[Select]During the next monthWithin three monthsBefore the end of the yearHow many employees would be eligible for the 401(k) plan?What percentage of eligible employees would you expect to participate?Investment OptionsWhat types of investment vehicles would you like to offer eligible employees? Mutual Funds Self-Directed Brokerage Account Need more information to decide Do you plan on matching any portion of the employee contribution?YesNoAdditional InformationInformation RequestIn our experience, we have found that there are several roadblocks — lack of goals, inappropriate investments, and procrastination — that keep most people from achieving financial success. Your ability to pursue your financial goals may depend on how well you are able to steer clear of these roadblocks. Topic(s) of Interest Risk Management Cash Management Investment Planning Retirement Planning Estate Conservation Describe your specifci topic(s) of interest:Any additional information to consider as we process your request?PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
