Life Insurance
Life Basics | Permanent Life | Term Life | Term Life Quote | Universal Life Quote | Needs Analyzer | Life Links | Glossary | Life Quote Form  

 

 

Secured Page

SECOND-TO-DIE LIFE QUOTE REQUEST
Complete the following information if you would like to obtain a quote on a Second-to-Die life insurance policy. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired. A Second-to-Die life insurance policy covers two insureds at the same time and pays benefits upon the second death. It is primarily used to pay estate taxes when due.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?
Last
First
Middle
What is your spouse's name?
Last
First
Middle
What is your address?
Street
City
State
Zip
What is your telephone number?
Telephone
What is your alternate telephone number?
Alternate Telephone
What is your e-mail address?
e-mail
What is your fax number?
Fax
Quote Information
What Benefit Amount do you want?
Benefit Amount
  Self Spouse
What is your birth date?
What is your gender?
Male Female
Male Female
What is your height? Height (example 5'8")
What is your weight?
lbs.
lbs.
Do you smoke or use tobacco?
Has you ever been treated for cancer, diabetes, or cardiovascular disorders in your life?
Yes No
Yes No
If yes, please describe
Have parents or siblings been treated for cancer, diabetes, or cardiovascular disorders prior to Age 60?
Yes No
Yes No
If yes, please describe
Are you taking any medication?
Yes No
Yes No
If yes, please give dosage and frequency
Explain any health problems that you think would impact the rate.
Have you had 2 or more moving violations in the last 2 years or any DUI's in the last 5 years?
Yes No
Yes No
If yes, please describe.
What is the amount of Current Life Insurance?
What are your current Life Insurance Companies?
What is your current monthly life premium?
Comments or Questions
Best Time to Contact You
Please let us know the best time to call and discuss your quote.
Morning
Afternoon
Evening
Anytime
Or specify other:

 

     
 
THE GLOVER AGENCY, LLC

145 E. BROAD STREET | EUFAULA, AL 36027
Phone 334-687-0358 or 888-882-2181
Fax 334-687-2365
 
 
This web site may contain concepts that have legal, accounting and tax implications. It is not intended to provide legal, accounting or tax advice. You may wish to consult a competent attorney, tax advisor, or accountant.
Privacy Statement