IMPORTANT NOTICE

1. This term life insurance quote request applies only to the states of Oregon and Washington. Do not fill out this form if you do not reside in Oregon or Washington.

2. No coverage will be started by submitting this form.

3. No matter what life insurance company you contact, or agent you talk to, when you receive a preliminary quote, there is no price guarantee and no coverage is bound. The premium quote is only an estimate based on the assumption that no problems will be uncovered during the underwriting period. After you apply for coverage, the insurance company will underwrite, or verify, the information received from you. When the underwriting is completed, the life insurance company will advise if it will issue a policy and how much the actual premium will be (which may be higher or lower than the preliminary quote).

4. Submitting this quote request constitutes your agreement with the above statements. We will contact you within two business days after we receive your request. If you have questions concerning this notice or about the following form, please call us at 503-620-0230 or toll-free 1-888-620-0230.

Life Insurance Quote Request
  1. Your First Name
    Invalid Input
  2. Middle Name
    Invalid Input
  3. Last Name
    Invalid Input
  4. Street Address
    Invalid Input
  5. City
    Invalid Input
  6. State
    Invalid Input
  7. Zip Code
    Invalid Input
  8. Phone Number
    Invalid Input
  9. Fax Number
    Invalid Input
  10. Email
    Invalid Input
  11. Date of Birth
    Invalid Input
  12. Gender
    Invalid Input
  13. Are You a U.S. Citizen?
    Invalid Input
  14. Face Amount ($100,000-$5,000,000)
    Invalid Input
  15. Term Period
    Invalid Input
  16. If you chose Universal or Whole Life above, please describe below in the Comments box the type of coverage you're looking for.
  17. Payment Mode
    Invalid Input
  18. Are you a smoker?
    Invalid Input
  19. Current Weight
    Invalid Input
  20. Current Height
    Invalid Input
  21. Occupation
    Invalid Input
  22. Describe all health problems during last 5 years
    Invalid Input
  23. Describe prescription medications you take
    Invalid Input
  24. Additional Information or comments
    Invalid Input
  25. Re-type the Security Field numbers in the box
  26. Security Field
    Security Field
      RefreshThe Security Code you typed did not match. Please "refresh" and try again.
  27. To keep a copy of this form, please Print before Submitting
  28.   

 

Network with BTIA

Follow us on Twitter & Facebook:
BTIA on Facebook  BTIA on Twitter
Share this page with your network:
AddThis Social Bookmark Button

Questions?

If you have questions concerning this information, please call us at 503-620-0230, or come in.

Llámenos ya al 503-620-0230.