Life Insurance Quote Form
* First Name:       Middle Initial:      * Last Name:   
Current  Street Address:


City:       County:       Zip Code:   
 
 
Proposed Insured's Information
(see our privacy statement)
Name: Date of Birth:
There are two basic types of life insurance.

The first type is Term. It is less expensive and meant to cover a specified number of years, or the "TERM." Term insurance is meant generally to replace income should the wage earner die while others are dependent on that person. We offer many types of term insurance. If you are looking for a specific type, just let us know. Chances are we offer what you want. The most common types are level premium with level death benefit over a term of 10, 20, or 30 years.
 
The Second type of coverage is Permanent. The group of permanent type policies (including Whole Life and Universal Life) are generally more expensive but are meant to last your entire life. We recommend that everyone carry at least some permanent insurance to pay for final expenses. There are many types of permanent life insurance policies. If you have a specific type of plan that you want, or specific needs, please indicate at the bottom of this form. Otherwise, we will provide you with a quote and explanation of the type of policy that seems to suit your needs the best.
 
We recommend you consider at least 5 times your annual earnings if you have dependents.

What type of Life Insurance are you interested in?
You may check more than one and we will provide a quote for each.
Level Term: Amount of coverage(50,000 to 1,000,000):
Mortgage Insurance: Amount of coverage(50,000 to 1,000,000):
Permanent Insurance: Amount of coverage(25,000 to 1,000,000):
 
Health Questions
Proposed insured's height: feet inches Proposed insured's weight: lbs
When was the last time the proposed insured smoked cigarettes, cigars, or used smokeless tobacco?

Has the proposed ever had any of the below conditions?
High Blood Pressure Yes No High Cholesterol Yes No
Heart Disease Yes No Cancer Yes No
Diabetes Yes No Been hospitalized in the last 7 years Yes No
Liver or Kidney Disease Yes No Any other diseases of any types Yes No

If you answered yes to any of the above please explain as thoroughly as possible giving an explanation of type of illness/disease, length of illness or hospital stay, type and amount of medications taken and current status of condition.
Has the proposed insured had a parent or sibling pass away before the age of 60? Yes No
If yes, please list relationship, age at death, and cause:
Has the proposed insured ever been convicted of DUI/DWI, reckless driving, or had their license suspended in the last 7 years? Yes  No
If yes please describe:
Does the proposed insured engage in or plan to engage in scuba diving, racing, or aviation?
If yes please explain:
Would you like us to include a quote for your child coverage rider of $10,000? Yes No

Please give us a brief description of why you are interested in life insurance. Please check all that apply.
I have children I want to make sure are taken care of in the event of my death.
I have a mortgage I want to make sure is paid off.
I want to provide coverage for any final expenses.
I have a spouse that I want to make sure is taken care of.
I want coverage to pay for my estate.
   
* How do you prefer to be contacted regarding your quote?
If by home or work phone, what time should we call?
* Home or work phone number:
* E-mail address:
 
If you have any other questions or comments please list them here.
 
Once you have filled out this form to the best of your knowledge please click on the submit button and an ACL Insurance Agent will respond with your quote within the next 24 hours. Please understand that if this information has not been filled out as accurately as possible, you quote may be inaccurate.

Please see our privacy page if you have any questions on security.
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