Products: Quoting Term Life Insurance
Below is the information usually needed to apply for life insurance. You may print this information and fax it to us at 503-620-7856. Or you may call us for a quote at 503-620-0230. For additional contact information, click here.
PLEASE NOTE: No coverage is bound until you receive verification from us confirming it.
Information we will need:
Date you want coverage to begin
How much coverage do you want?
Do you want the policy to last 5, 10, 15, 20, or 30 years?
Your full name
Phone #
Fax #
Email
Address
Date of Birth
SS#
Driver's License #
Male or Female
If female, are you currently pregnant?
Spouse’s name
Spouse’s SS#
Spouse’s Birthdate
Smoker or non-smoker?
If you previously smoked, how long ago did you quit?
Are you a US citizen?
If not a citizen, do you have a green card, have a valid social security number, reside in the USA legally and have permanent residency here?
Have you ever been treated or sought treatment for diabetes, heart disease, cancer, or cardiovascular disease, cholesterol, high blood pressure?
Has your father, mother, brother or sister been treated for or passed away before age 65 from cancer or heart disease?
If so, at what age and from what condition?
Have you been treated for alcohol or drug use in the last 10 years?
What is on your driving record the last five years?
Have you had any DUIs in the last 10 years?
PLEASE NOTE: No matter what life insurance company you contact, when you receive a preliminary quote, it is not guaranteed 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. To find out what coverage will actually cost, you must apply for it. The insurance company will then check your information and verify the condition of your health. When the underwriting is completed, the company will advise if it will issue a policy and how much the actual premium will be.
Even though there is no guarantee of coverage, it is beneficial for the applicant to pay the initial estimated payment at the time of application. That way, the life insurance becomes effective at the time of application (barring disqualifying underwriting) instead of at some point after delivery. If the applicant passes away in that gap of time, his/her beneficiaries would certainly be looking for coverage!
PLEASE NOTE: The policy coverages are limited to the terms and conditions that are written into the application and/or the policy by the insurance company. When you receive your policy or information about it from the insurance company, please read it.
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