Life Insurance

    The amount of Life Insurance your family needs is an extremely personal decision.  At Balanced Financial Solutions, we can help you decide the amount and type of Life Insurance you need, whether it's Term, Universal or Whole Life.  In your later years,  Single Premium Whole Life Insurance can sometimes almost double the value of your estate.  Unlike the "quote only" sites, we take the time to carefully evaluate your needs.  Each quote is personalized to your specific needs and situation. Just complete the form below, and a specialist will contact you.
 
 


STEP 1

What is your zip code?
Is any applicant a smoker? Yes        No
What is your date of birth?  
Gender Male      Female
Height   
Weight lbs.
Occupation

STEP 2

Have you been rated or declined for health or life insurance in the last 5 years? Yes         No
Have you been hospitalized in the last 5 years? Yes         No
Have you had a DUI/DWI in the last 5 years? Yes         No
Have you been a resident of the U.S. or Canada for the last 12 months? Yes         No
Do you currently take prescription medications? Yes         No
If yes, please list medication names and dosages:
Have you ever been diagnosed with or been treated for any of these medical conditions? (check all that apply)
AIDS/HIV Alcohol Abuse (last 3 years only) Alzheimer's Disease
Cancer (last 10 years only) Cerebral Palsy COPD
Coronary Artery Disease Diabetes Type I Diabetes Type II
Drug Abuse (last 3 years only) Emphysema Epilepsy
Fibromyalga Heart Attack Heart Disease
Hepatitis C High Blood Pressure High Cholesterol
Hypertension Kidney Disease Kidney Stones
Liver Disease Multiple Sclerosis Stroke
Vascular Disease    

STEP 3

Do you currently have a life insurance policy? Yes        No
If so, with what company?
Do you want coverage for your spouse? (If applicable) Yes        No
Do you want coverage for your children? (If applicable) Yes        No
What type of life insurance coverage are you interested in?
(Select one policy type, coverage amount, and option below)
  Type Coverage Amount Option
Term
Permanent
Other (Not Sure)

STEP 4

First Name
Last Name
Address
Address 2
City    
Daytime Phone ( ) - 
Evening Phone ( ) - 
Fax Number ( ) - 
Email 
Best Time to Contact You Morning        Afternoon        Evening
How soon do you need this policy?
Additional Comments
How would you like to be contacted? 
 
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