Life Markets Quote Form

Aries insurance services, a division of URL.

Life Markets

Life Markets Quote Request Form

*core life carriers chart*

Date Needed*

Agent First Name*	Agent Last Name*

Agent Phone*

Agent Fax

Agent Email*

How do you want your quote?*

Email

Fax

Phone Call

Client First Name*	Client Last Name*

Client Gender*

Male

Female

Client Income*

Client Occupation*

Client Date of Birth*

Tobacco Use*

N/A

Chew

Cigarette

Cigar

Nicotine Gum

Pipe

Rate Class*

Super Preferred

Preferred

Standard

Sub Standard

Client Height*	Client Weight*

Client Medical Concerns?

Death Benefit*	State of Sale*

Do you need a term quote?*

Yes

No

Term Length

10

15

20

25

30

Do you need a permanent quote?*

Yes

No

Type

Universal Life

Indexed UL

Whole Life

Any Riders?*

Yes

No

Mode of Premium*

A

SA

Q

M

Desired Company/Companies*

For Universal Life & Indexed UL

What is the most important to you and your client?

Lowest cost age 100 guaranteed

Age 100 guaranteed with good cash value

Specified cash value

Cash accumulation

Lump sum money?

Yes

No

If yes, $

1035 Exchange*

Yes

No

Specified Premium

Yes

No

If yes

Specified cash value solve?

Yes

No

If yes

Special Instructions