Step 1: Personal Information

Name

Email

Phone Number

Date of Birth

Gender Male Female Other

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Step 2: Coverage Preferences

Coverage Type

Term Life Insurance Whole Life Insurance Universal Life Insurance Endowment Plans

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Step 3: Coverage Amount

Desired Death Benefit $100,000 $250,000 $500,000 $1,000,000 Other

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Step 4: Policy Term

Desired Term Length 10 years 20 years 30 years Lifetime (Whole Life)

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Step 5: Add-Ons

Add-Ons

Accidental Death Benefit Critical Illness Rider Waiver of Premium Child Term Rider

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Step 6: Budget

Annual Premium Budget Less than $500 $500 - $1,000 $1,000 - $2,000 More than $2,000

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Step 7: Health Information

Do you smoke?

Yes No

Do you have any pre-existing medical conditions?

Yes No

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