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Second-to-Die Life Quote Request
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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.
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Your Name
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Spouse’s Name
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Mailing address
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What Benefit Amount do you want?
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Self
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Spouse
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What is your birthdate?
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What is your gender?
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What is your height? Height (example 5' 4")
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Inches
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Inches
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What is your weight?
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Do you smoke or use tobacco?
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Have you ever been treated for cancer, diabetes, or cardiovascular disorders in your life?
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Yes No
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Yes No
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If yes, please describe
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Have parents or siblings been treated for cancer, diabetes, or cardiovascular disorders prior to Age 60?
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Yes No
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Yes No
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If yes, please describe
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Are you taking any medication?
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Yes No
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Yes No
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If yes, please give dosage and frequency
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Explain any health problems that you think would impact the rate.
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Have you had 2 or more moving violations in the last 2 years or any DUI’s in the last 5 years?
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Yes No
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Yes No
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If yes, please describe.
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What is the amount of Current Life Insurance?
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What are your current Life Insurance Companies?
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What is your current monthly life premium?
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