Your Contact Info
First Name Last Name
Home Address? (street, city, zip)
Email
Your Phone Number?
Best Time to Call? AM PM any time
Would you like us to telephone or email you with the quote?
Telephone Email
Policy Requirements
Quote type Level Term Life Universal Life Ordinary Whole Life Variable Life Second-to-Die Universal Life
If requesting Level Term Life, number of years of level premium desired? 5 10 15 20 30
Purpose of Policy? Survivor Needs Estate Planning Mortgage Protection Other
Date of Birth (month/date/year )
Married? Yes No
Will your spouse also be applying for Life Insurance? Yes No
Tell Us About Yourself
Weight? (lbs)
Occupation?
Have you ever used tobacco or any other product containing nicotine? Yes No
If you've quit, please give the date you most recently used.
Reason for quitting?
In the past 5 years, have you had your Driver's License suspended or had 3 moving violations and/or accidents? Yes No
In the past 5 years, have you been convicted of or plead guilty or no contest to driving under the influence of alcohol or drugs? Yes No
Are you a member of, or considering joining the Armed Forces, including the Reserves? Yes No
In the past 5 years, have you filed for bankruptcy or had any liens for judgements filed against you? Yes No
In the past 5 years, have you flown or do you intend to fly, other than as a passenger? Yes No
In the past 5 years, have you traveled or resided, or do you intend to travel or reside outside the Continental U.S. for more than six consecutive weeks? Yes No
In the past 2 years, have you engaged in, or do you expect to engage in, any hazardous activities or sports such as hang gliding, hot air balloning, ultra-light flying, mountain or rock climbing, motor or boat racing, scuba or skydiving? Yes No
Father's age if living, or, age of death and cause.
Mother's age if living, or, age of death and cause.
Please list all physical and mental health conditions for which you have been treated, or recommended to get treatment, in the last 10 years: (please list Condition, Treatment, Date(s) treated and Degree of Recovery)
Please list all medications currently being taken: (Condition treated, medication name and milligrams, dosage per day, date first prescribed).
How did you hear about Beacon Insurance?
