Life Insurance Quote Request

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.

Your First Name

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Middle Name

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Last Name

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Street Address

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City

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State

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Zip Code

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Phone Number

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Fax Number

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Email

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Date of Birth

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Gender

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Are You a U.S. Citizen?

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Face Amount ($100,000-$5,000,000)

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Term Period

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If you chose Universal or Whole Life above, please describe below in the Comments box the type of coverage you're looking for.
Payment Mode

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Are you a smoker?

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Current Weight

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Current Height

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Occupation

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Describe all health problems during last 5 years

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Describe prescription medications you take

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Additional Information or comments

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Re-type the Security Field numbers in the box
Security Field

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