Quote Request

Quote Request Form

Please be as thorough as possible. The more information you provide the better equipped I'll be to match your case with the appropriate carrier/product. Thank you!

Advisor Contact Information:

* Indicates required field

Advisor Name *

First

Last

Phone Number *

Email *

Client Information:

Client Name *

First

Last

DOB: *

Contract State *

Face Amount? *

Policy Type *

Height *

Weight *

Weight change past 12 months *

Tobacco use past 5 years *

If YES, date of last use *

Type of tobacco *

Medications *

Health History (please be as specific as possible and include onset age of each condition). *

Hospitalizations past 5 years (dates, reason and outcome). *

Any surgeries in the past 5 years (dates, reason and outcome). *

Family Deaths prior to age 60 *

Please explain *

Hazardous Activities *

Please provide details *

Do you plan to travel outside the US/Canada in the next year? *

Please provide details *

Adverse driving record past 5 years *

Please provide details *

Please provide any additional information you feel is pertinent to this case *

Any history of drug or alcohol abuse? *

Please provide details *

Actions taken by other carriers (include dates). *

Submit

For more information:
LifeStar Brokerage
192 Cherokee Rd
Asheville, NC 28804
Email: jpaoletti@lifestarbrokerage.com
310-309-0997