Second-to-Die Life Quote Request

Please fill out the following form to obtain a quote on a Second-to-Die life insurance policy. Once we receive this quote request, we will send you an application appropriate for the coverage you requested. A Second-to-Die life insurance policy covers two insured individuals at the same time and the benefit is paid upon the second death. In general, this type of policy is used to pay estate taxes when due. Remember, this form is not an application for insurance.

Any information provided on this for is held strictly confidential and will only be used for developing a quote for you.

Personal Information

Your Name

Last

First

Middle

Spouse's Name

Last

First

Middle

   

Mailing address 

Street

City

State

Zip

Telephone Number

Alternate Telephone Number

E-mail Address

Fax Number

 

Quote Information

What Benefit Amount do you want?

Benefit Amount

Self

Spouse

What is your birthdate?

What is your gender?

Male

Female

Male

Female

What is your height? Height (example 5'10")

    Inches
   Inches

What is your weight?

lbs.

lbs.

Do you smoke or use tobacco?

Have 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:

 



Financial Services Group
Burlington, WA 98233
Phone: 360-755-1428 Toll Free: 1-888-755-1428 Fax: 360-755-0285 Email: mjones@yourretirementplanningsource.com  

Securities and advisory services offered through Cetera Advisors LLC, member FINRA/SIPC. Cetera is under separate ownership from any other entity. 

230 Broadway, Lynnfield MA 01940 800-949-1422

This site is published for residents of the United States only. Financial Advisors of Cetera Advisors LLC, may only conduct business with residents of the states and/or jurisdictions in which they are properly registered. Not all of the products and services referenced on this site may be available in every state and through every advisor listed. For additional information please contact the advisor(s) listed on the site, visit the Cetera Advisors LLC site at www.ceteraadvisors.com.


Michael Jones is licensed to do business in the following states: AL, AZ. CA, CO, IN, OR, WA.

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