"Use Zander's online quoting system to search for the most competitive term life insurance plans available. Remember most people with families need 10 times their income in coverage and I recommend 15, 20 or 30 year guaranteed level plans depending on your age. Stay away from Cash Value or Return of Premium plans that waste your money. Zander only deals with top notch insurance companies and has great rates... even for those with pre-existing conditions. Call them at 800.356.4282 with any questions. They are there to help."
- DAVE RAMSEY

Term Life Insurance: Send Me a Proposal

Click Here to Include Spouse/Partner Information

denotes Required Answers

You
Your Spouse/Partner
General
Your Full Name
Gender
Male Female
Date of Birth
- -
(mm-dd-yyyy)
Residence
Address 1
Address 2
City
State
Zip Code
Contact
E-Mail Address
(you@example.com)
Home Phone
(xxx-xxx-xxxx)
Work Phone
(xxx-xxx-xxxx)
Mobile Phone
(xxx-xxx-xxxx)
Fax Phone
(xxx-xxx-xxxx)
Please answer the following questions carefully.

This information is very important in helping us provide you with the best and most accurate information available.

Also, please answer any Follow-Up Questions when they appear. These are used to provide additional information.
Questions
Have you used any form of tobacco in the last 5 years?
(This includes cigarettes, chewing tobacco, snuff, etc.)
Yes No
Please indicate the quantity and type of tobacco used by yourself:
Examples:
Cigarettes, 20 per day, Yesterday
Chewing tobacco, once daily, 3 years ago
Have you had any history of drug use or substance abuse?
Yes No
Please list what was used and date of last use, if you had in-patient or out-patient care, and how long you were in treatment.
Have you had any ongoing or past treatment of medical conditions including, but not limited to, stroke, diabetes, heart disease, cancer, high blood pressure, cholesterol, sleep apnea, anxiety, depression or any other treatment?
Yes No
List those past treatment of medical conditions, age at diagnosis, and how you are treating condition:
Do you currently take any prescription drugs?
Yes No
Please provide reason for medication and dosage:
Are you currently pregnant?
Yes No
Please provide current weight, trimester and if you have ever been diagnosed with gestational diabetes or any other pregnancy related condition?
Is there any history of your immediate family (Mother, Father or siblings) with a history of heart disease or cancer prior to their age of 70?
Yes No
Please provide health condition, how they are related to you, their age at diagnosis, and if they passed away age at death:
Do you participate in any form of hazardous sports?
Yes No
Please provide details:
Do you currently or have you in the past flown as a pilot commercial or private?
Yes No
Please provide details:
Are you currently in the military or national guard?
Yes No
Provide occupation details:
Have you ever declared bankruptcy?
Yes No
What chapter did you file?
What was/is the discharge date?
Height
Example:
5 ft 6 in
ft. in.
Weight
Example:
120 lbs.
lbs.
Have you had a weight loss of more than 10 pounds in the past 12 months?
Yes No
Please advise method of loss (diet, exercise, surgical, medication, etc.) and how much weight has been lost in the past 12 months:
Have you had any speeding tickets or DUI's in the last 5 years?
Yes No
Please provide details:
Are you a US citizen?
Yes No
What type of VISA do you (or your spouse/partner) hold?
Do you intend to travel out of the US in the next 2 years?
Yes No
Please list when, where, duration, and the purpose of visit:
Do you need a child insurance rider on your policy?
Yes No
Do you currently have a Life Insurance policy in force?
Yes No
Will you be replacing an existing policy?
Yes No
Life Policy Information
How much coverage would you like quotes for?
List the term period you would like to see:
Years
Face Amount