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To obtain a level premium quote, simply answer
the following questions.
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| A quote will be provided for a
5, 10, 20, and 30 year guaranteed term rate for each face amount selected.
Please call Phil Sudweeks directly at (801) 501-8470 or (801)
766-8476. if you desire a
proposal for a permanent policy (UL Universal Life, Whole Life, etc.).
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Required Fields *
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E-mail
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*
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Full Name
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*
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Work Phone
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Home Phone
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*
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Age
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Height
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| Weight
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| Insurance
Needed
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face amounts)
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,000
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,000
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,000
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,000
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| 1). Do you have a personal
history of cardiovascular disease, diabetes, or cancer (except for
minor, non-melanoma skin cancer)?
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| 2). Do you have a family
history (parents/siblings) of death prior to age 60, due to
coronary artery disease or diabetes (Type II)?
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| 3). Do you have a family
history (parents/siblings), prior to age 60, of diagnosis or death
from cancer (except for minor, non-melanoma skin cancer), coronary
artery disease or diabetes?
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| 4). Do you have a personal
history of alcohol or drug abuse, or counseling/treatment for
alcohol or drug usage within the last 10 years? If yes are you abstinent?
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5). Do you fly as a
pilot or crew member, except for regularly scheduled major U.S. or
Canadian passenger airline?
Private aviation considered with an Aviation Exclusion Rider.
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| 6). I have engaged in a hazardous sport or occupation.
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| What was the sport
or occupation?
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| 7). Have you been
convicted of a felony within the last 10 years?
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| 8). Have you used
nicotine within 2 years?
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| 9). Have you used
nicotine within 1 year?
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| 10). My total
cholesterol
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| 11). My
cholesterol/HDL ratio
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| 12). My current
motor vehicle (MVR) record has
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| violation(s) in the last 3 years, and
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| , and
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no driving
under the influence (DUI) convictions within the last
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| 13). I am a US
Citizen
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| If not a US Citizen
I have been a US resident for at least one year and have a permanent
resident status
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| 14). I repeated or prolonged travel to underdeveloped countries or
areas of political unrest.
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15). Please add any additional comments you may have.
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Please remember that the quotes provided are on the basis of the
information provided by you. Complete underwriting of your full medical
history and other factors will be required to determine whether you are
eligible for coverage.
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