Kleinschmidt Insurance—Life Insurance Quote Request

QUOTE FORMS

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CLAIMS

Please complete this form as completely and accurately as possible and submit it to us when you are finished. If you wish, you may also print out the form and fax it to us (734•662•5379) or call our office with this information.

Note that we cannot provide coverage until a policy or binder has been issued by the insurance company. As part of our quoting process, we may need to verify some information such as credit history, prior insurance history, and financial stability information.

Contact Information
Name:
Street address:
City:
State:
Zip code:
County:
Phone (home):
Phone (work):
Fax:
Email address:
Quote Information
Date of birth (mm/dd/yy):
Gender: Male Female Smoker: No Yes
Height (ex. 5'8") Weight (ex. 150 lbs) Private pilot? Yes No
Amount of insurance needed ($25,000–$3M):
Policy type: Annual Renewable Term Level Term Whole Life Universal Life Second-to-Die Not sure	Policy duration: 10 or more years 15 or more years 20 or more years 25 or more years 30 or more years My whole life
Please describe any and all health conditions you have (or have had in the past):

Additional Considerations/Requests
Please add any additional comments you feel appropriate for this quotation.