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Home
Agent Tools
Doing Business with DIL
Needs Analysis
Life Quotes
LTC | DI | Annuity Quotes
Underwriting Forms
XRAE Underwriting Tool
Underwriting Tools
Contracting & Licensing
Policy Service
Core Carriers
Sales & Marketing
Annuity
Disability
Long Term Care
Life Insurance
About
About Us
Meet the Team
Contact Us
Your Life Department
Life Insurance Quote Request
Life Proposal Request
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Agent First Name
Agent Last Name
Email Address
License #
PROPOSED INSURED INFO
Proposed Insured First Name
Proposed Insured Last Name
Date of Birth
State of Residence
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Alabama
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Rhode Island
South Carolina
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Texas
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Gender
Male
Female
Risk Class
-Select-
Unknown - please assist
Preferred Best
Preferred
Standard Plus
Standard
Impaired Risk - Rated
Nicotine Use
-Select-
No use of any type ever
No Cigarette use for 5+ years
No Cigarette use for 3+ years
No Cigarette use for 12+ months
Cigarette use in last 12 months
Cigar use only
Chewing tobacco use only
Nicotine gum/patch only
Other (explain below)
Marijuana Use
-Select-
No use ever
No use in last 5 years
No use in last 12 months
Use 5-7 times per week
Use 1-3 time per week
Use occasionally - please define below
Medical Problems and History
Comments
PRODUCT SELECTION
Premium Mode
-Select-
Annual
Semi-annual
Quarterly
Monthly - EFT
Face Amount 1
Alternative Face Amount 2
Face Amount 3
Product Type
Annual Renewable Term
10 Year Level Term
15 Year Level Term
20 Year Level Term
25 Year Level Term
30 year Level Term
35 Year Level Term
40 Year Level Term
Guaranteed Universal Life
Current Assumption Universal Life
Index Universal Life
Whole Life
Short Pay Options - For Permanent Plans Only
Single Pay (1 year Only)
5 Year Pay
10 Year Pay
20 Year Pay
Pay to age 65
Pay to age 75
Other - record in Comments
Premium Solve Options - For Permanent Plans Only
Lowest Level Premium to keep policy in-force for Life
Lowest Level Premium to keep policy in-force to age 100
Lowest Level Premium to keep policy in-force to age 90
Other - please describe in comments
Riders
Waiver of Premium
Child Rider
Accidental Death
Chronic Illnes or LTC
Return of Premium
Other - list in Comments section
Company Choices
Comments
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