Consumer Driven Healthcare Consultants Indianapolis - Great Midwestern Financial Group

Call Today Toll Free: (866)259-5020

What type of quote would you like to receive?	Universal Life Quote Variable Life Quote Life Quote Form
Personal Information
What is your name?	Last
	First
	Middle
What is your address?	Street
	City
	State
	Zip
What is your telephone number?	Telephone
What is your alternate telephone number?	Alternate Telephone
What is your e-mail address?	e-mail
What is your fax number?	Fax
Quote Information
What Benefit Amount do you want?	Benefit Amount
How many years would you like a Guaranteed Level Premium?	Term Length	Years
What is your purpose for buying Life Insurance Protection?
What is your birth date?	Birth Date
What is your gender?	Gender	Male Female
What is your height?	Height (example 5'8")
What is your weight?	Weight	lbs.
Do you smoke or use tobacco?	Tobacco Use
Have you ever been treated for cancer, diabetes, or cardiovascular disorders in your life?	Yes No If yes, please describe
Have parents or siblings been treated for cancer, diabetes, or cardiovascular disorders prior to Age 60?	Yes No If yes, please describe
What medications are you taking?	Yes No If yes, please give dosage and frequency
Are there any health problems that you think would impact the rate?	Explain
Have you had 2 or more moving violations in the last 2 years or any DUI's in the last 5 years?	Yes No If yes, please describe
What is the amount of Current Life Insurance?	Amount of Current Life Insurance
What are your current Life Insurance Companies?	Current Life Insurance Companies
What is your current monthly life premium?	Current Monthly Life Premium
Comments or Questions

Best Time to Contact You
Please let us know the best time to call and discuss your quote.	Morning Afternoon Evening Anytime	Or specify other:

3815 River Crossing Parkway • Suite 100 • Indianapolis, In 46240
Phone: (866)259-5020 • Fax: (317)705-0050 • Email: jack@greatmidwesternfinancialgroup.com