Life Insurance Quote Request

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.

Insured Name:*

Second Insured Name (optional):

Date of Birth:*

Second Insured Date of Birth:

Height & Weight:*

Second Insured Height & Weight:

Gender:*

Male
Female

Second Insured Gender:

Male
Female

State:*

Second Insured State:

Tobacco User?*

Yes
No

Second Insured: Tobacco User?

Yes
No

If yes, what type and how often:

Second Insured: If yes, what type and how often:

If used in past, when did you quit?

Second Insured: If used in past, when did you quit?

Plan Design

Payment Mode:*

Desired Plan Length:*

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)

Additional Comments, health concerns, medications? Current and past health history, family history (cancer/heart related issues/deaths), major driving violations (DUIs), specific carrier requests, goal of case, etc. Please include dates.

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.