Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by providing your personal information. Fill in the fields for advisor name, advisor phone, and your email address.
3. Next, enter your client name and specify your gender.
4. Provide your birth date for age verification.
5. Indicate your state of residence.
6. Fill in your height and weight as these will be used for risk assessment.
7. List any medications you are currently taking and any known medical impairments.
8. Specify if you are a tobacco user by marking Yes or No, and include the type of tobacco used.
9. State the date of your last tobacco use.
10. Provide details of your family history, specifically noting any occurrences of heart disease, cancer, or diabetes in your parents or siblings, along with their ages at time of occurrence.
11. Indicate if you have submitted or received offers from other insurance carriers.
12. Next, specify your desired quote information. Choose the term coverage you’re interested in, such as 10-year, 15-year, 20-year, or 30-year.
13. For permanent coverage, select the type, including Universal Life, Survivorship Universal Life, Index Universal Life, Variable Universal Life, or Whole Life.
14. Enter the desired death benefit amount and input the premium details.
15. If applicable, specify if this is a 1035 exchange and the years you wish to pay the premium.
16. Indicate your cash value goal at a given age and any additional notes relevant to your insurance needs.
17. Once completed, you can save your changes, download, print, or share the form as needed. Finally, be sure to email it to dhenry@elementinsurancepartners.com or fax it to 260-627-2222.

Start completing your Life Insurance Quote Request Form online to explore your options today!