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Life Insurance Quote Request
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Life Insurance Quote Request
Life Insurance Quote
Agent Name:
*
Agent Company:
Agent Email:
*
Agent Phone:
*
Has this client been declined life insurance in the last year?
Yes
No
If Face Amount is UNDER $250,000, please
click here for the Guaranteed Issue WL Calculator
to run your own quote.
Click here
for the Accidental Death Calculator.
If the Face Amount is OVER $250,000, please complete the health questionnaire at
https://www.ociservices.com/wp-content/uploads/2019/09/HealthQuestionnaireForm.pdf
. If you have any questions please contact us at
lifesales@ociservices.com
.
*Captive Agents Only* – If case was not previously declined, please provide reason for submitting through OCI and not your parent company:
Will the face amount be $25,000 or under?
Yes
No
Please
click here for the Final Expense Calculator
.
Insured Name:
*
Date of Birth:
*
Date Format: MM slash DD slash YYYY
Height:
*
Weight:
*
Gender:
*
Male
Female
State:
*
Tobacco User?
*
* Includes e-cigs, vapes, nicotine gum and patches.
Yes
No
If yes, what type and how often:
If used in past, when did you quit?
Are you currently a U.S. citizen or permanent resident with a valid visa?
Yes
No
If No, please explain:
Will this be a Second-To-Die Plan?
Yes
No
Second Insured Name:
Second Insured Date of Birth:
Date Format: MM slash DD slash YYYY
Second Insured Height:
Second Insured Weight:
Second Insured Gender:
Male
Female
Second Insured State:
Second Insured: Tobacco User?
* Includes e-cigs, vapes, nicotine gum and patches.
Yes
No
Second Insured: If yes, what type and how often:
Second Insured: If used in past, when did you quit?
Plan Design
Payment Mode:
*
Annual
Semi-Annual
Quarterly
Monthly
Desired Plan Length:
*
10 yr
15 yr
20 yr
25 yr
30 yr
35 yr
Permanent - GUL, IUL, WL
Most important aspect of permanent policy?
Cash Accumulation (supplemental retirement income)
Guaranteed Death Benefit
How much does client want to contribute to plan on a monthly basis?
Desired Death Benefit:
*
Riders:
Waiver of premium
Child Rider
Critical/Chronic Illness and/or LTC (available on permanent products only)
Case Design Notes – specific product, carrier, goal of case, etc. Please note if you discussed this case with an OCI sales representative or if you’re in competition with another carrier.
Underwriting Prescreen
Has your client been treated for any of these conditions? (check all that apply)
*
Alcohol or substance abuse
Asthma
Blood pressure
Cancer
Cholesterol
Depression or anxiety
Diabetes
Heart issue
Sleep apnea
None of the above
Please elaborate on any of the above conditions or any medical condition not listed. Please provide dates, treatment, and outcome.
VERY IMPORTANT: Over 35% of life insurance cases are rated or declined. Eliminate the surprise for your client and increase your closing percentage by asking your client about any known health conditions. Specifically ask if they have diabetes, cardiac conditions, depression/anxiety, sleep apnea, or cancer.
List any prescription medications taken during the past two years. Please list purpose, dosage, and frequency.
Does your client have any major driving violations (DUIs) or participate in any hazardous activities? Please provide dates and number of occurrences.
By clicking Submit, I certify all information is true and accurate to the best of my knowledge.
