To gauge your client’s insurability, have them fill this out as completely as possible. We will use this form to find the best product for your client. You can use the Word document to fill out and email back to us, print the PDF for the client to fill out (then fax it to us) OR use the form below and click submit.

  • Writing Agent Information

  • Client Information

  • Family Health History

  • List all siblings age(s), age(s} at death, cause of death(s), age(s) at onset.
  • Client Health History

  • If yes, provide date(s), reason, results, future surgery(s) required.
  • No need to list dosage.
  • If yes, list dates, reason, results, future plans, etc.
  • If yes, list dates and description.