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LIFE INSURANCE QUOTE REQUEST

While most people consider their Life Insurance coverage to be an invaluable asset, many seldom think about reviewing their coverage to keep abreast of their ever changing needs. Whittaker & Associates stands ready to assist you in evaluating your insurance needs to assure that you maintain a proper level of coverage and protection consistent with your particular objectives.  From your "personal" needs such as Mortgage payoff, Education funding, Retirement and Estate Planning to "business planning" needs (Key Person, Buy-Sell Agreement, Deferred Compensation, etc.), we possess the expertise necessary to provide you with professional advice and offer qualified recommendations based upon your specific needs and objectives.  From "super-preferred" to "impaired risk" placement, we work directly with underwriters at many top rated insurance companies to assure that you receive the best value in insurance coverage available in today's competitive Life Insurance marketplace.

For a "qualified" quote, please complete the following information, or call us today to discuss your specific needs and objectives.

Insured #1

Name:

Birth Date: mm/dd/yyyy
Gender:M F
Height Weight
Tobacco Use: Pipe Cigar Chewing
Cigarettes (If quit, last used)
Pre-existing conditions:
Medication & Dosage:

Insured #2

Name:

Birth Date: mm/dd/yyyy
Gender: M F
Height Weight
Tobacco Use: Pipe Cigar Chewing
Cigarettes (If quit, last used)
Pre-existing conditions:
Medication & Dosage:

ILLUSTRATION:

PRIMARY OBJECTIVE:

Death Benefit Cash Accumulation Guarantees Low Premiums

Face Amount(s):  $

Other:

PRODUCT TYPE:

Universal Life  Whole Life  Whole Life Blend

% Term Survivorship

Term  ART  5 10 15 20 25 30 "Return of Premium" option

Other:

 

Do you have any family history (parents or siblings) of cardiovascular disease or cancer before age 60?
Yes     No   
Do you have any family deaths (parents or siblings) due to cardiovascular disease or cancer before age 60?
Yes     No   

Within the past 10 years have you received medical or surgical consultation, advice or treatment (including medication) for any of the following: Stroke, heart or circulatory system disorders, liver disorders, kidney diseases, emphysema, rheumatoid arthritis, ulcerative colitis, diabetes, cancer, alcohol/drug abuse, immune system disorders (including HIV infection) or tested positive for HIV infection?
Yes     No   

If you answered yes to any of the above: Please explain: 

* Required

* Name
* E-mail
* Tel
* Address 
*City
*State
*Zip

 

 

Privacy Statement

                   

 

Employee Benefits Specialists

For A FREE Consultation Call

Toll Free 877-399-7077 or (609) 399-7177

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Copyright © 2004 Whittaker & Associates. All rights reserved.
Revised: August 01, 2007 .

 

 

 

 

 

 

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