MJ Marketing


To request a quote please select, fill out and submit the desired form below. MJ Marketing will get back to you as soon as we can regarding your request. * indicates a required field.

Life Insurance


Life Insurance Quote Request Form

Agent Information

Name: *     Email: *

Phone # *     Fax #

Address *     City: *

State: *     Zip: *

Client Information

Name:     Gender:

Date of Birth: / /

Height:   Weight:     Smoker:

Resident State:     Client Status:

Medications and Brief Medical History:

Client Spouse Information:

Name:     Gender:

Date of Birth: / /

Height:   Weight:     Smoker:

Spouse State:     Spouse Status:

Medications and Brief Medical History:

Illustration Information:

Life Product Type:

Term/Survivor Guarantee Period: years

 Guaranteed Issue    Simplified Issue    Graded Issue

Specified $:   Face or $: Premium
OR Solve for $:   Face or $: Premium
Cash Value of $: at age: or year:

Premium Mode:

Premium Payment Period:
 Continuous Single Pay Limited Pay for

Solve for Income:   Age to Start:   Age to Stop:

Specified Income $:   or Maximum Income $:

Will there be a 1035 exchange?:

Current Death Benefit $:

 Option A Option B
Change option at age: to

Riders:  Child Rider Units Spouse Rider Units Term Waiver of Premium

Competitive Info — Company to compete with:

Face $:   Premium $:
Cash at age 100 $:

A+ company required?:
Guarantee to age 100 required?:
Will this be part of an ILIT?:

Business use?:
 Key Man Business Continuation 412i Pension Buy/Sell




 

Long Term Care


Long Term Care Quote Request Form

Agent Information

Name: *     Email: *

Phone # *     Fax #

Address *     City: *

State: *     Zip: *

Client Information

Name:     Gender:

Date of Birth: / /

Height:   Weight:     Smoker:

Medications and Brief Medical History:

Client Spouse Information:

Name:     Gender:

Date of Birth: / /

Height:   Weight:     Smoker:

Medications and Brief Medical History:

Long Term Care Information:

Benefit Amount: Daily   Monthly   Cash Benefit

Waiting Period:   Premium:

Benefit Period:   Inflation Protection:

Rate Class Desired:   Payment Option:

Additional Notes: