Empower Brokerage – Life Insurance Quote Information
Agent Name: ______________________________________________ Agent Phone: ____________________
Agent Email: _________________________________________________________
Client(s) Name – Full name(s) as it would appear on the illustration:__________________________________________
Residence State: ______ Date of Birth: _______________ Male [ ]
Height: _____ Weight: _____ Tobacco User: Yes [ ] No [ ]
Female [ ]
If so, what type of tobacco ___________________
Underwriting Process – Simplified Issue [ ] (Policy is still underwritten, but a medical is not required)
Fully Underwritten [ ] (Full medical must be received or underwriting will not be completed.)
Summary of Insurance Need: What type of Ins. (Term [How Long],
Permanent); Purpose (Death Benefit only, cash accumulation,
College, Retirement Income, etc.)
What is your client wanting this insurance to accomplish?
(The more information, the more accurate the quote)
How Much Life Insurance Is Needed?
Use the D.I.M.E.
D (Death and Debts) =
$_____________
I (Income) 10 x Gross =
$_____________
M (Mortgage or Rent x 10) $_____________
Underwriting:
Any major health issues in the past 5 years? Yes [ ]
E (Education) =
$_____________
Total
$______________
No [ ] If yes, what they are, when diagnosed and outcome.
List of Medications: (List type, frequency, dosage and what it is for.)
Additional Information/Conditions/Requests/Instructions or for Survivor Policies:
Notes: (Office Use Only)