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Leading Edge Insurance - The Disability Income and Life Insurance Specialists
     

 

Term Express Quick Entry Form

Please enter the basic information for the Proposed Insured in the fields presented below.  This information will be used to initiate the process for the life insurance application. When you have answered all of the questions, review your answers and click the Submit This Form button at the bottom of the page to continue.
 Proposed Insured Information

 

  

      Contact  Name (or Agent name):  

1.
Insured Name:
First
Middle (no initials, please)
Last
 
Home Address:  How long at this address?
 
  City:  County:  State:  Zip: 
 
Mailing Address (only if different than home)
  City
  		 State: 
  		 Zip
 
2.
 Male    Female
3.

Birth Date
(MM/DD/YYYY)
or
(MMDDYYYY)
  State of Birth, 
         or
Country of Birth

 
  Issue Age (nearest birthday)
    
4.

Social Security Number
(use dashes:   xxx-xx-xxxx)
5.
Are you a U.S.Citizen or permanent U.S.resident?  Yes    No If "No", what country?
If "No", how long in the United States?
6.
E-Mail Address:  
 
7.
Telephone Number: ()
   Work       (use dash) 		()
   Home    (use dash) 		             
Best Time To Call
 Owner Information
8.
Owner is Proposed Insured, or
Owner's Name, if other than Proposed Insured
(If two or more persons are designated, their interests shall be joint and survivor.)
 
  Relationship to Insured :
 
Owner's Address
  City
  		 State:  Zip
 
 
Owner's Social Security Number or Federal Tax ID 
  
 Beneficiary Information
9.
Primary Beneficiary(ies)  ("Children" shall mean children born to or legally adopted by the Insured.)
  Name   Relationship to Insured  Percentage
 
10.
Contingent Beneficiary(ies) , list Contingent Beneficiary(ies) and select Relationship to Proposed Insured
  Name Relationship Percentage
 
 
Is Contingent beneficiary a trust or estate?    
 
Trust Full Name
 Date of Trust
 Trustee's Name
 Life Plans
11.
Plan of Insurance
Amount   
12.
Tobacco User      Yes No
13.
Underwriting Class   Super Preferred
Preferred
Select
Standard
     Underwriting Class selection help
14. Premium Mode   Annual Semi-Annual Quarterly Monthly Bank Draft List Bill
  Is employer paying the premium?   Yes No
 Life Riders and Benefits
15.
Riders and Benefits  
Waiver of Premium Rider for Total Disability
Family Term Life Insurance Rider
     Amount:  Death benefit, each child
Accidental Death Benefit Rider
     Amount:  Death benefit
 Premium Information/Temporary Insurance Coverage
16.
Has any person proposed for coverage been diagnosed or treated for heart attack, stroke, or cancer within the last two years; or been advised to have any surgery which has not been performed? If yes, please explain in comments box below)  Yes    No
 
 Replacement Information
17.
a. Does the Proposed Insured have existing life insurance or annuity contract(s) in-force
or is the Proposed Insured applying for other life insurance? Yes No
b. Will this policy replace or cause change in any existing policy or contract? Yes No
If either 19a or 19b is answered "Yes" , list all policies and/or contracts below and indicate whether the proposed policy will replace or cause change in any existing policy:
Company or Source
 		 Type of Insurance
 		 Face Amount of Insurance
 		 Will it Be Replaced?
 		 Replacement Date
(mm/dd/yyyy)
 
Yes
No
Yes
No
Yes
No
Yes
No
 
 
 Agent Contact Information
18. Telephone Number  
  FAX Number  
  E-Mail Address
  Comments