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Request Permanent and Term Life Insurance Quotes BenefitHouse.com is your one-stop shopping place for life insurance. We are independent insurance agents representing all of the top life insurance companies. We will find the best policy and lowest premium for you based upon your needs and goals. Underwriting guidelines for life insurance can vary significantly from company to company. Please answer the following questions completely for an accurate quote. Fields in red text are required. Your information will be used only for its intended purpose and will not be disclosed for any other reason. Privacy Policy.
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Policy Request

How much insurance would you like?
What is the purpose of this insurance?
How long do you want coverage to last?
When do you need your coverage to start?
Any special requests:

Contact Information

First Name:
Last Name:
Address:
City:
State, Zip Code:

Daytime Phone:
Evening Phone:
Method of contact:	Home Work
Best day/time to call:	AM PM
Email:

Personal Information

Gender:	Male Female
Marital Status:
DATE OF BIRTH:
Occupation:

Ever used tobacco?	Yes No
Type/quantity used & if quit, when?
Replace existing policy?	Yes No
If yes, company:

Duties:

Employer:
Address:
City:
State, Zip:

US Citizen?	Yes No
If no, country of citizenship:
City/State of Birth:
Years at present address:
Prev. address if under 5:

Beneficiary Information

Primary Beneficiary:
Relationship:

Contingent Beneficary:

Activities

Are you a private pilot or do you fly in an airplane as anything other than a passenger?	No Yes
Do you participate in Ballooning, Parachuting, or Hang Gliding?	No Yes
Do you Scuba dive over 60 feet in depth?	No Yes
Do you participate in Mountain Climbing requiring ropes or other devices?	No Yes
Do you race motor vehicles?	No Yes
Do you participate in any other dangerous activities?	No Yes
Have you traveled outside the US in the past 2 years, or do you plan to travel outside the continental US within the next 6 weeks?	No Yes

If yes to any of above, please explain:

Legal Information

Have you ever been convicted of reckless driving or had your license suspended or revoked?	No Yes
Have you ever been convicted of DUI?	No Yes
Have you ever been convicted of a felony or a crime other than driving violations?	No Yes

If yes to any of above, please explain:

Financial Information

Yearly Income:
Net worth:
Have you ever declared bankrupcy?	No Yes
If yes, explain:

Health Information

HEIGHT: ft inches *( Height Must Be Included for Accurate Quote )*
WEIGHT: lbs. *( Weight Must Be Included for Accurate Quote )*
Has insured ever been treated for AIDS, ARC, or HIV?	No Yes
Has insured ever been treated for heart disease, chest pains, high blood pressure, or disease of the heart or blood vessels?	No Yes
Have you ever been treated for Cancer or a tumor of any kind?	No Yes
Have you ever been treated for disorders of any internal organs?	No Yes
Have you ever been treated for depression or other serious mental illness?	No Yes
Have you ever been advised to seek drug or alcohol abuse counseling?	No Yes
Have you experienced a weight loss of more than 10 pounds or 10% of body weight in the past year?	No Yes
Have you been hospitalized within the last 10 years?	No Yes
Have you ever been disabled or filed a workers compensation claim?	No Yes
If yes to any of above, please explain:
Please list any medications that you are taking or have been advised to take including the name, dosage and for what condition:
Please list the names, addresses and phone numbers of physicians you see. Also, describe the condition insured sees them for and the treatment received.

Family History

Father:	Living Deceased
Age/Age at death:
Cause of death:

Mother:	Living Deceased
Age/Age at death:
Cause of death:

Siblings: (If not all living, cause and age of death)

Owner Information: (Complete if proposed insured is not the policy owner)

Owner Name:
Relationship to Insured:

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Licensed to sell life insurance in:

Florida License #D072714, California License #0C94325, Ohio License #104233

Licensed agents in: Alabama, Alaska, Arizona, Arkansas, Florida, Georgia, Hawaii, Illinois, Indiana, Idaho, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Minnesota, Mississippi, Michigan, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, California, Colorado, Connecticut, Delaware, D.C., South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, Wisconsin, Wyoming