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On-Line Life Insurance
Quotation Form
One Simple Form - takes only 2-3 Minutes!

Your Personal Data:
Your Name:
Street Address:
Zip Code:
E-Mail again for accuracy:
Fax (optional):
Primary Insured's Occupation:
Are You Married?
Yes No
Currently Insured?
Yes No
If currently covered list carrier, # of years covered, and type of coverage
Unusual Activities?
(If you engage in unusual activities such as scuba diving, airplane flying, rock climbing, etc., list them here.)

Underwriting Information:
Name of Proposed Insured:
Enter Proposed Insured's Birthdate:  
Sex (M/F): Do You Smoke?:
Height: Weight:
Spouse's Information:
(Leave Blank if you do NOT want Spouse Coverage)
Name of Spouse:
Enter Spouse's Birthdate:  
Sex (M/F): Do You Smoke?:
Spouse Height: Spouse Weight:


Amount of Coverage Desired?
Type of Life Coverage Desired?
TERM = Pays death benefit only - This is lowest cost for coverage.
UNIVERSAL LIFE = Has savings aspect in addition to providing death benefit.
OTHER = Would be mortgage protection, whole life, no-exam life, etc.
Years of Level Premium, if selecting term life.
List Any Health Problems:
Reason for Buying Life Insurance:
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Jay P. Stoetzer Insurance
5750 W. 95th Street, Suite 105 | Overland Park, KS 66207
Toll-Free: 855-EZQUOTE
Local Phone: 913-221-7764 | Fax: 913-385-3500
About Our Agency | Privacy Notice | Office Map/Directions

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