Farmers Insurance Group

LIFE INSURANCE

For a Life Insurance Quote:

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Based on the information you provide, we will provide you with a quote. We will send it by email, fax, or telephone. You make the choice on how you wish to receive the information

Information needed for a Life Insurance Quote:

GENERAL INFORMATION

Name:

Address:

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Phone:

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LIFE INFORMATION

Date Of Birth:

Sex:

Male Female

Height:

Weight:

Occupation:

TYPE OF LIFE INSURANCE

Term a*	Permanent Insurance f*
Annual Renewable Term b*	Ordinary Whole Life g*
10 Year Guaranteed Level Term c*	Universal Whole Life h*
15 Year Guaranteed Level Term d*
20 Year Guaranteed Level Term e*
SUPPLEMENTAL BENEFITS AND OPTIONS
Insured Childrens’ Rider (ICR) j* Accidental Death Benefit (ADB) k* Guaranteed Insurability Option (GIO) l* Waiver of Premium (WP) m*
HEALTH QUESTIONS
Please describe your general health Excellent – athletic, no medications Good, no infirmities, no medications Fair, slightly overweight, taking medication Poor, have had serious health condition
Tobacco Use Never smoked or used nicotine Used to smoke, quit less than 1 year ago Used to smoke, quit 1-2 years ago Used to smoke, quit 2-3 years ago Used to smoke, quit 3-4 years ago Currently Smoke or use Nicotine cigars/pipe/chew/patch
a* Term Life Insurance - Life insurance which provides protection for a specified period of time. A death benefit is paid to the beneficiary if the insured dies within a specified period of time while the policy is in force. b* Annual Renewable Term - Term Insurance which is take out for 1 year. It may be renewed at the end of each year but at the rate for the new age of the insured. c* 10 year Guaranteed Level Term - Term Life Insurance which is taken out for a period of 10 years. Life insurance is guaranteed not to change premium and to remain in force for 10 years as long as premiums are paid. d* 15 year Guaranteed Level Term - Term Life Insurance which is taken out for a period of 15 years. Life insurance is guaranteed not to change premium and to remain in force for 15 years as long as premiums are paid. e* 20 year Guaranteed Level Term - Term Life Insurance which is taken out for a period of 20 years. Life insurance is guaranteed not to change premium and to remain in force for 20 years as long as premiums are paid f* Permanent Life Insurance - Life insurance which last for the lifetime of the insured. Premium is generally the same each year until the Death of the insured. g* Whole Life Insurance - Permanent life insurance which provides protection for life. As long as premiums are paid, a death benefit is paid to the beneficiary. The premiums are designed to remain level over time. In addition, these policies accumulate cash value on a tax- deferred basis. h* Universal Whole Life. - Permanent Life insurance which provides protection for life as long as the premiums are paid. The premiums are flexible and the death benefit adjustable. j* Insured Childrens’ Rider – Provides term life insurance coverage on each child of the insured’s family. k* Accidental Death Benefit - An additional death benefit will be paid if you die by accident. l* Guaranteed Insurability Option - Guarantees that you may purchase additional life insurance in the future without proof of insurability. m* Waiver of Premium - the insurance company will continue to make your life insurance premium payments if you become disabled.