5738 Foremost Drive, SE Grand Rapids, MI  49546
Phone 616-956-0040, 616-949-0490 or 800-530-9221
 
 

Individual Insurance Quote Request

 

You must fill out 1 form for each person that is requesting coverage.

Each area must be completed to be considered for that insurance coverage.

When you've completed the appropriate sections, you must click on the SUBMIT button on the bottom of the page to send your information to us.

Basic Applicant Information

First and Last Name:                                                                          Requested Agent:

                                                   

Address:

City:                                          County:                       State:                         Zip:

     

Phone:

Email (optional):

 

Insured

Spouse

(if applying)

Child

(if applying)

Child

 (if applying)
Date of Birth:

Gender:

 
Height:

Weight:

 

      
Smoker:

   
Significant Health Conditions:

Current Medications:

 

Requested Effective Date:

Coverages Desired:

Life   Health   Disability   Dental   Long-term Care

 

Life Insurance Information

Term Permanent
Length of term desired:

    Whole Life
Amount:

    Universal Life
    Other
   

Amount:
     
Will this life insurance be replacing current coverage? 

 

Health Insurance Information

Standard Plan Design

Office copay amount:
Individual Deductible:
Co-Insurance:

HSA Plan Design (high deductible with separate health saving account)

 

Disability Insurance Information

Occupation:

Annual Income (as stated on W-2 or 1099 or combined):    

Benefit period:

Elimination period:

 

Long-term Care

Types of Contracts: (choose 1)
  Indemnity
  Reimbursement
Types of Coverage: (choose 1)
  Long-term Care Facility
  Professional Home and Community Care
 

Both (not available on Reimbursement Contact)

 

Optional Features

 

Cash surrender, refund is a % of premium paid

 

Return of premium at death

 

Inflation protection

 

Payment Options

 

Single Pay

 

5 year pre-payment

 

10 year pre-payment

 

To age 65 pre-payment

 

Duration of Benefits:

Elimination Period:

 

Dental

Coming soon!

 

Additional Comments

Please add 3 and 4 and enter the sum in box below.

 

 

All submitted information is considered confidential.