Broker Quotes

Please complete all areas of the form as best as possible. The more accurate the information, the easier it will be for us to provide the best policy for your client. To protect your client’s privacy, first and last names are not required fields to be completed. However, we must have your name, email, and accurate phone number to contact you with your client’s quote.

FOR INSURANCE AGENTS ONLY

Date (Format MM-DD-YYYY)*
Agent Name*
First Last
Agent Email*
Agent Phone*
Agent Fax
Agent Website
CLIENT INFO
Name
Prefix First Middle Last Suffix
Address
Street Address Address Line 2 City State ZIP Code
U.S Citizen?
- Yes
- No
Gender
- Male
- Female
Date of Birth (Format MM-DD-YYYY)
Height
Weight
Employment
- Full Time
- Part time
- Retired
- Unemployed
Occupation
Do You Smoke?
- Yes
- no
Have you ever had, been told you had or have been treated for any of the conditions listed?
- Yes
- No
If yes, check all that apply:
- Alcohol Abuse
What was the date of initial treatment or diagnosis?
Were there any relapses from sobriety/abstinence?
- Yes
- No
If Yes, Please list dates
If Yes, Please list dates
Were there any legal problems (such as DUI) or other?
- Yes
- No
If Yes, please give details including dates
If Yes, please give details including dates
- Heart murmur valve disease
If your client has an Aortic Valve Disorder, please answer the following: How long has this abnormality been present?

(Years)
Please check the type(s) of Aortic Valve Disorder present
- Aortic Stenosis
- Aortic Insufficiency
Have any of the following occurred?
Chest Pain
- Yes
- No
Palpitations
- Yes
- No
Trouble Breathing
- Yes
- No
Dizzieness, Fainting
- Yes
- No
Heart Failure
- Yes
- No
Is there a history of any other heart disease in addition to the aortic valve disorder (problems with other valves, coronary artery disease, etc.)?
- Yes
- No
If Yes, please give details
If Yes, please give details
Have additional studies been completed? (check all that apply)
- Echocardiogram
- Cardiac Catherization
- None
If Echocardiogram

(Date)
If Cardiac Catherization

(Date)
Is your client on any medications?
- Yes
- No
If Yes, please give details
If Yes, please give details
Has your client smoked cigarettes in the last 12 months?
- Yes
- No
- Asthma
Please list date when first diagnosed
Have you ever been hospitalized for this condition?
- Yes
- No
Yes, please give details
Yes, please give details
How many episodes of Asthma have you had in the past year that required you to go to the ER or see a physician for treatment?
Have you ever smoked?
- Yes Currently
- Yes smoked in the past but quit
- Never Smoked
If Yes, and currently smoke

(amount/day)
If Yes, smoked in the past but quit

(date)
Are you on any medications (include inhalers) or any medications taken on an "as needed" basis?
- Yes
- No
If Yes, please give details
If Yes, please give details
Have pulmonary function tests (a breathing test) ever been done?
- Yes
- No
If Yes, please give most recent test results
If Yes, please give most recent test results
Do you have any abnormalities on an ECG or x_ray?
- Yes
- No
If Yes, please give details
If Yes, please give details
- Hepatitis
Please list date of diagnosis
Was the hepatitis due to...
- Hepatitis A
- Hepatitis C (non_A/non_B)
- Hepatitis B Resolved
- Hepatitis B, Carrier or Chronic Infection
- Other
If Other, please specify
If Other, please specify
Please give the date and results of the most recent liver enzyme tests
a)AST/SGOT
a)AST/SGOT
b)ALT/SGPT
b)ALT/SGPT
c)GGTP
c)GGTP
Are you on any medications?
- Yes
- No
If Yes, please give details
If Yes, please give details
Do you drink alcohol?
- Yes
- No
If Yes, please note amount and frequency
If Yes, please note amount and frequency
Please check if any of the following studies have been completed
- Liver Ultrasound
- Liver Biopsy
- No Further Evaluation
a) Liver Ultrasound or CT scan
a) Liver Ultrasound or CT scan
- Normal
- Abnormal
b) Liver Biopsy
b) Liver Biopsy
- Normal
- Abnormal
Have you been diagnosed with any of the following?
- Chronic Hepatitis
- Cirrhosis
Have you been treated with infection or anti_viral drugs?
- Yes
- No
If Yes, please give details
If Yes, please give details
- Cancer
Please note type of cancer diagnosed
List date of first diagnosis
How was the cancer treated? (check all that apply)
- Surgery
- Chemotherapy
- Radiation Therapy
- Hormonal Therapy
- Immunotherapy
List date treatment was compleated
Please list stage and grade of the cancer
Are you on any medications?
- Yes
- No
Yes, please give details
Yes, please give details
Has there been any evidence of recurrence?
- Yes
- No
Yes, please give details
Yes, please give details
Have you smoked cigarettes in the last 12 months?
- Yes
- No
- Irregular heartbeat/palpitations
Please list date when first diagnosed
Is the irregular heart beat due to (check all that apply)
- Premature Supraventricular Atrial Beats (PAC's)
- Premature Ventricular Beats(PVC's)
- Multifocal
- Bigeminy or Trigeminy
- Ventricular Tachycardia
Are there any symptons with the irregular heart beat?
- Dizzyness (light_headness)/Faint Feeling
- Palpatations
- Chest Discomfort
Have any fo the following tests been done? If so, please give date and results
- ECG
- Stress Test
- Echocardiogram
- Holter Monitor
ECG Results
ECG Results
Stress Test Results
Stress Test Results
Echocardiogram Results
Echocardiogram Results
Holter Monitor Results
Holter Monitor Results
Are you on any medication?
- Yes
- No
Yes, please give details
Yes, please give details
The cause of the irregular heart beat is due to
- Heart Disease
- Alcohol
- Thyroid Disease
- Unknown
Have you smoked in the last 12 months?
- First Choice
- Second Choice
- Third Choice
- Cirrhosis
- Kidney disease
If your client has had an abnormal kidney function test, please answer the following...
Please list diagnosis:
Please check if condition is present
- Polycystic Kidney Disease
- Glomerulonephritis
- Nephrosclerosis
- Systemic Lupus
- Erythematosus
- Other
Is your client on any medications?
- Yes
- No
Yes, please give details
Yes, please give details
Please give most recent results of kidney function tests
BUN
BUN
Serun creatinine
Serun creatinine
Urinalysis
Urinalysis
Please provide height and weight
Height
Height
Weight
Weight
Please note if any of the following have occured (check all that apply)
- Frequent Infections
- High Blood Pressure
- Cardiovascular Disease
Has your client smoked cigarettes in the last 12 months?
- Yes
- No
Does your client have any other major health problems? (ex:c cancer,etc;)
- Yes
- No
Yes, please give details
Yes, please give details
- COPD
Type of lung disease
- Emphysema
- Restrictive Lung Disease
- Asthma
Please list date when first diagnosed
Have you ever been hospitalized for this condition?
- Yes
- No
Yes, please give details
Yes, please give details
Have you ever smoked?
- Yes Currently
- Yes smoked in the past but quit
- Never Smoked
If Yes, and currently smoke (amount/day)
If Yes, and currently smoke (amount/day)
If Yes, smoked in the past but quit (date)
If Yes, smoked in the past but quit (date)
Are you on any medications (include inhalers)?
- Yes
- No
Yes, please give details
Yes, please give details
Has pulmonary function tests (a breathing test) ever been done?
- Yes
- No
If yes, please give most recent results
If yes, please give most recent results
What is your...
Height
Height
Weight
Weight
Do you have any abnormalities on an ECG or x_ray?
- Yes
- No
If yes, please give details
If yes, please give details
- Lupus
Please list date of first diagnosis
Please note type of lupus diagnosed
- Systemic Lupus Erythematosus(SLE)
- Discoid Lupus
- Drug Induced SLE
Is your client on any medications?
- Yes
- No
If Yes, please give details
If Yes, please give details
Please note if the lupus is
- In Remission
- Currently Present
In Remission (list date of last exacerbation)
In Remission (list date of last exacerbation)
Please check if your client has had any of the following
- Meurologic Disorder
- Lung Involvement (Pleuritis)
- Heart Involvement (Pericarditis)
- Proteinuria
- Renal Insufficiency or Failure
- High Blood Pressure
Has your client smoked cigarettes in the last 12 months?
- Yes
- No
- Coronary artery disease (CAD)
Please list date(s) and type of the coronary revascularization procedure
Have you had any of the following?
- Heart Attack
- Bypass Surgery
Heart Attack Date:
Heart Attack Date:
Bypass Surgery Date
Bypass Surgery Date
Are you on any medications?
- Yes
- No
If yes, please give details
If yes, please give details
Has a follow_up stress (exercise) ECG been completed since the revascularization procedure?
- Yes Normal
- No Abnormal
- No
If Yes - Normal (date)
If Yes - Normal (date)
If Yes - Abnormal (date)
If Yes - Abnormal (date)
Have you had any chest discomfort since the revascularization procedure?
- Yes
- No
If Yes, please give examples
If Yes, please give examples
Have you had any of the following?
- Elevated Cholesterol
- Diabetes
- Overweight
- Family History of Heart Disease
- High Blood Pressure
Have you smoked in the last 12 months?
- Yes
- No
If Yes, please give details
If Yes, please give details
- Multiple Sclerosis
Please list date of first diagnosis
Please indicate the number of episodes and date of last episode
Are you on any medications?
- Yes
- No
If yes, please give details
If yes, please give details
Please note current neurologic status and/or symptoms.
- Normal
- Minimal Residual Impairment
- Moderate Residual Impairment
- Severe Residual Impairment
If Minimal Residual Impairment (please specify)
If Minimal Residual Impairment (please specify)
If Moderate Residual Impairment (please specify)
If Moderate Residual Impairment (please specify)
If Severe Residual Impairment (please specify)
If Severe Residual Impairment (please specify)
Please provide all MRI brain scan reports
Have you smoked cigarettes in the last 12 months?
- Yes
- No
- Chron's disease
Please list date of first diagnosis
Are you on any medications?
- Yes
- No
If Yes, please give details
If Yes, please give details
Have you had any of the following?
- Hospitalization for this Disorder
- Surgery for this Disorder
- Colonoscopy
If Hospitalizations for this disorder (list dates)
If Hospitalizations for this disorder (list dates)
If Surgery for this disorder (list dates)
If Surgery for this disorder (list dates)
If Colonoscopy (list dates of most recent)
If Colonoscopy (list dates of most recent)
Please fill out the following
Height
Height
Weight
Weight
Have you smoked in the last 12 months?
- Yes
- No
- Peripheral Vascular Disease
Please list date of diagnosis and arteries involved
Have you had any of the following treatments? (if Yes, please note dates)
- Angioplasty
- Bypass Grafting
Angioplasty Date
Angioplasty Date
Bypass Grafting Date
Bypass Grafting Date
Are any of the following present (check all that apply)?
- Bruit heard by Physician
- Diminished Pulses
- Claudication Pain with Activity
- Ankle - Brachial Blood Pressure Ration
Are you on any medications?
- Yes
- No
If Yes, please give details
If Yes, please give details
Please check if you have had any of the following: (check all that apply)
- Abnormal Lipid Levels
- Diabetes
- High Blood Pressure
- Chest Pain
- Coronary Artery Disease
- Cerebrovascular or Carotid Disease
Have you smoked cigarettes in the last 12 months?
- Yes
- No
If Yes, please give details
If Yes, please give details
- Depression/anxiety
Please list date of diagnosis
Please indicate date(s) of episode(s)
Are you on any medications?
- Yes
- No
If Yes, please give details
If Yes, please give details
Do you have a history of substance abuse (alcohol or durgs)?
- Yes
- No
If Yes, please give details
If Yes, please give details
Have you been hospitalized, required ECT, been seen in the emergency room, or been on disability for psychiatric symptoms or treatment?
- Yes
- No
If Yes, please give dates
If Yes, please give dates
Have you smoked cigarettes in the last 12 months?
- Yes
- No
If Yes, please give details
If Yes, please give details
- Rheumatoid Arthritis
Please list date of first diagnosis
Are you on any medication?
- Yes
- No
If Yes, please give details
If Yes, please give details
Please check if you have had any of the following
- Weight Loss
- Lung Disease
- Fever
- Liver Enzyme Abnormality
- Low Blood Counts
- Kidney Disease
- Heart Disease
Which joints are involved?
Please list functional ability
- Fully Active
- Sedentary
- Uses Walker
- Uses Wheelchair
Have you smoked in the last 12 months?
- Yes
- No
- Diabetes
Please list date when first diagnosed
How often do you visit your physician?
(also note date of last visit)
How do you control your diabetes?
- Diet Alone
- Oral Medication
- Insulin
If Oral Medication (dose
If Oral Medication (dose
If Insulin, (amount of units/day)
If Insulin, (amount of units/day)
Are you on any other medications?
- Yes
- No
If Yes, please give details
If Yes, please give details
Please give most recent blood sugar reading
Do you monitor your own blood sugar?
- Yes
- No
If available, please give the most recent glycohemoglobin(HbAlc) or fructosamine level
Please check if you have had any of the following
- Chest Pain or coronary
- Overweight
- Artery Disease
- Elevated Lipids
- Protein in the Urine
- Kidney Disease
- Neuropathy
- Black Out spells
- Retinopathy
- Hypertension
- Abnormal ECG
Have you smoked cigarettes in the last 12 months?
- Yes
- No
- Sleep Apnea
Please list date of diagnosis
Was the sleep apnea diagnosed as...
- Obstructive
- Central
- Mixed
- Unknown
How is the sleep apnea being treated?
- Observation Alone
- Weight Loss
- CPAP/BiPAP
- Surgery
- Other
If Other please explain
If Other please explain
Are you on any medications?
- Yes
- No
If Yes, please give details
If Yes, please give details
What is your weight and blood pressure?
Weight
Weight
Blood Pressure
Blood Pressure
Please check if you have any of the following
- Lung Disease
- Accidents such as Motor Vehicle Accidents
- Heart Disease
- Arrhythmia
- Stroke
- Depression
Have you smoked cigarettes in the last 12 months?
- Yes
- No
Please note date of most recent sleep study

(date)
Please attach a copy of the of most recent sleep study report.
Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 100 MB.
.pdf, .doc, .docx only please
- Drug Abuse
What was the date of initial treatment or diagnosis?
What drug(s) were used or abused?
Were there any relapses from sobriety/abstinence?
- Yes
- No
If Yes, please list dates
If Yes, please list dates
Were there any legal problems (such as DUI or other)?
- Yes
- No
If Yes, please give details including dates
If Yes, please give details including dates
Have there been physical complications or additionsl psychiatric problems?
- Yes
- No
If Yes, please give details
If Yes, please give details
Please list current medications
What is your current level of alcohol consumption?
Do you currently participate in a group such as Narcotics Anonymous?
- Yes
- No
Have you smoked cigarettes in the last 12 months?
- Yes
- No
- Stroke
Please list date(s) of CVA(s)
Are you on any medications?
- Yes
- No
If Yes, please give details
If Yes, please give details
Do you have any current neurological residuals?
- Yes
- No
If Yes, please give details
If Yes, please give details
Have you smoked cigarettes in the last 12 months?
- Yes
- No
Please check if you have any of the following
- High Blood Pressure
- Diabetes
- High Cholesterol
- Peripheral Vascular Disease
- Coronary Artery Disease
- Heart Murmur
- Atrial Fibrillation
- Carotid Disease
- Epilepsy
Please list date of first diagnosos/type of seizure
Please note the type of seizure
- Complex/Partial Seizure
- Tonic_Clonic Seizure
- Absnese Seizure
- Myoclonic Seizure
Please indicate the number or frequency of episodes and date of last episode
Is your client on any medications?
- Yes
- No
If Yes, please give details
If Yes, please give details
Have you been hospitalized for treatment of epilepsy?
- Yes
- No
If Yes, please give details
If Yes, please give details
Have you smoked cigarettes in the last 12 months?
- Yes
- No
- Other Problems
Please Explain
Has anyone in your family, parents, grandparents ever had, been told they had or has been treated for any of the conditions listed above?
- Yes
- No
If Yes, please indicate all that apply...
If Yes, please indicate all that apply...
Check one or more of the following motor vehicle related incidents if they occured in the past 10 years
- Moving violation
- Reckless driving
- DUI/DWI
- License suspended/revoked
Have you ever been convicted of a felony?
- Yes
- No
Do you intend on visiting an underdeveloped country or place with political unrest in the next 24 months?
- Yes
- No
In the past 5 years have you, or do you intend to participate in any any of the following activities? Check all that apply
- Flying
- Sky diving
- Racing
- Scuba diving
DESIRED COVERAGE
Type of policy
- Term
- Permanent
If Permanent, select one
- Universal Life
- Whole Life
*Amount of coverage you want
*Amount of coverage you want
Desired length of Term insurance policy
Preferred insurance company
If you are not sure about a company, leave blank and we will make a recommendation for you.
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FOR INSURANCE AGENTS ONLY

CLIENT INFO

DESIRED COVERAGE

Click Here to read what some of our Agents/Brokers say about Excalibur!

Consumers! Need a Term Life, Guaranteed Issue, Final Expense, Impaired Risk Life Insurance quote?

A life insurance broker committed to making a difference by getting you the low cost life insurance you want.

FOR INSURANCE AGENTS ONLY

CLIENT INFO

DESIRED COVERAGE

Click Here to read what some of our Agents/Brokers say about Excalibur!

Consumers! Need a Term Life, Guaranteed Issue, Final Expense, Impaired Risk Life Insurance quote?

A life insurance broker committed to making a difference by getting you the low cost life insurance you want.

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