Quote Request

First Name:

Last Name:

Street Address:

City:

State:

Zip:

eMail:

Best Time to Call:

Home Phone:

Business Phone:

FAX:

DOB:

Smoker?

Yes No

Gender:

Male  Female

Height:

Weight:

Pay Grade &
Annual Salary:

Federal Branch
& Location:

Do you currently have
"FEGLI" option B?

Yes No

If so, how many times
your current salary?

1  2   3  4  5  NA

Are you in good health?

Yes    No

If no, please list conditions:

How much insurance
do you need?

Are you under a doctor's care?

Yes    No

If so, please list dates and reasons:

Do you take any medications?

Yes    No

If so, please list reason name and dosage:

What do you want your
insurance to do for you and your family?

Income to family in case of death
Mortgage Protection
Child's Education
Estate Protection
Pension Maximization
Replacing Existing Insurance
Thrift Plan Rollover
Long Term Care

Would you like a quote for other family members?

Yes    No

If so, please list name, DOB and amounts: