West Coast Global InsuranceServices

www.InsureMeWC.com

West Coast Global Insurance Life Insurance Online Questionnaire | Global Life Insurance, Disability & Long Term Care Online Questionnaire

West Coast Global Insurance Services

Ca.Lic. #0E50745

USA - (818) 788-5353

Mex - 01 (800) 099 0614

Request Quote - Life Insurance Online Questionnaire | Global Life Insurance, Disability & Long Term Care Online Questionnaire


INSURED DETAILS (PRIMARY)

BENEFICIAL OWNERS DETAILS

CONTACT DETAILS

I have Whats App? : Yes No

LOCATION DETAILS


WHAT TYPE OF LIFE INSURANCE POLICY ARE YOU LOOKING TO SECURE ?


TERM LIFE INSURANCE

The most cost effective Life Insurance available and can be purchased for a term of 10, 15, 20 & 30 years based on age. Term Insurance has an end date based on the term selected.

ROP OR RETURN OF PREMIUM IS ALSO TERM INSURANCE :

Return of premium (ROP) is a type of life insurance policy that returns the premiums paid for coverage if the insured party survives the policy\'s term, or includes a portion of the premiums paid to the beneficiary upon the death of the insured.

PERMANENT INSURANCE (WHOLE LIFE & UNIVERSAL LIFE INSURANCE) :

An umbrella term for life insurance plans that do not expire (unlike term life insurance) and combine a death benefit with a savings portion. The two main types of permanent life insurance are whole and universal life insurance policies.

FINAL EXPENSE

(Benefits from $5,000 to $40,000) Final expense also known as burial insurance is designed to cover the bills that your loved ones will face after your death. these costs will include medical bills and funeral expenses.

LONG TERM CARE

A continuum of medical and social services designed to support the needs of people living with chronic health problems that affect their ability to perform everyday activities.

ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE

Covers death, dismemberment, loss of sight, loss of income, and medical expenses caused by accidental injury.

$50,000 - $500,000 of guaranteed issue coverage * Ages 18-70 * Coverage to age 80 * 5 minutes to quote and bind online

I AM NOT SURE YET, I NEED HELP MAKING THIS DECISION


 

 

HAVE YOU CONSIDERED A MONTHLY BUDGET FOR THIS LIFE INSURANCE POLICY? : Yes No

ARE YOU SEEKING LIFE INSURANCE PROTECTION FOR ANY ADDITIONAL FAMILY MEMBERS?* Yes No

PRIMARY APPLICANT

1.) Enter the death benefit amount's you are seeking protection for?

$
$
$
$

2.) Provide the reason/s for requesting a life insurance policy?

BUSINESS PROTECTION

FAMILY PROTECTION

ESTATE PLANNING

FINAL EXPENSES (BURIAL COSTS)

I NEED HELP TO DECIDE

3.) Annual income?

$

PRIMARY APPLICANT / PRE-UNDERWRITING MEDICAL QUESTIONNAIRE

4.) Have you ever applied for life insurance in the past?:&/or do you have any life insurance active now?

5.) Do you currently participate in any private aviation activities (not including scheduled commercial flights)?

6.) Have you ever been treated for high blood pressure11?

7.) Are you currently being treated for high cholesterol?

8.) Have you had any history with drug or alcohol abuse?

9.) Have you had any history of internal cancer, melanoma or heart disease?

10.) Do you have diabetes?

11.) How many medications are you taking?

12.) Do you participate in or have you participated in any hazardous sports or avocations within the last three years (i.e. hang gliding, ballooning, motorized racing, parachuting or scuba diving)?

13.) Do you use any nicotine products?

14.) Have you ever used any nicotine products?

15.) Have you had a dui and/or a reckless driving citation in the past 5 years)?

16.) Have you received a felony conviction in the past 10 years?

17.) Have you filed for bankruptcy in the last 5 years?

18.) Have any one of your natural parents or siblings had any history of or death from cancer, heart disease or cardiac related conditions?


Comments:

DIGITAL SIGNATURE

I acknowledge that West Coast Real Estate & Insurance, Inc., doing business as West Coast Global Insurance Services, does not guarantee any coverages and has presented this informal application/questionnaire solely for the purpose of collecting general information. I comprehend that the submission of this informal application/questionnaire does not constitute insurance coverage for either myself or the insured item for which I am seeking information.

I am aware that the coverage limits I have requested may be subject to change upon the generation of a formal quote by an insurance company. It is my responsibility to thoroughly review the coverages and policy conditions at that time. I confirm that I have read the foregoing application/questionnaire, along with any attached documents, and declare that the information provided therein is true, complete, and correct to the best of my knowledge and belief. I understand that this information serves as an inducement for the company to consider issuing an insurance policy, and no coverage is currently being offered.

I acknowledge that West Coast Real Estate & Insurance, Inc., DBA West Coast Global Insurance Services, will be in communication with me to further assist with my insurance needs. I hereby grant my consent to receive telephone calls, text (SMS & MMS) messages, and email communications. I understand that providing consent is not a condition of purchase, and standard message and data rates may apply. For more information on how your data is handled, please visit our Privacy Policy. (PRIVACY POLICY)
Checking this box serves as my digital signature.

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