Life Insurance Quote Request

Agent Name:*

Agent Company:

Agent Email:*

Agent Phone:*

Has this client been declined life insurance in the last year?

Yes
No

If Face Amount is UNDER $250,000, please click here for the Guaranteed Issue WL Calculator to run your own quote. Click here for the Accidental Death Calculator.

If the Face Amount is OVER $250,000, please complete the health questionnaire at https://www.ociservices.com/wp-content/uploads/2019/09/HealthQuestionnaireForm.pdf. If you have any questions please contact us at lifesales@ociservices.com.

*Captive Agents Only* – If case was not previously declined, please provide reason for submitting through OCI and not your parent company:

Will the face amount be $25,000 or under?*

Yes
No

Please click here for the Final Expense Calculator.

Please choose the OCI Sales Executive helping you with this case:*

Insured Name:*

Date of Birth:*

Height:*

Weight:*

Gender:*

Male
Female

State:*

Tobacco User?*

* Includes e-cigs, vapes, nicotine gum and patches.

Yes
No

If yes, what type and how often:

If used in past, when did you quit?

Are you currently a U.S. citizen or permanent resident with a valid visa?

Yes
No

If No, please explain:

Will this be a Second-To-Die Plan?

Yes
No

Second Insured Name:

Second Insured Date of Birth:

Second Insured Height:

Second Insured Weight:

Second Insured Gender:

Male
Female

Second Insured State:

Second Insured: Tobacco User?

* Includes e-cigs, vapes, nicotine gum and patches.

Yes
No

Second Insured: If yes, what type and how often:

Second Insured: If used in past, when did you quit?

Plan Design

Payment Mode:*

Desired Plan Length:*

Most important aspect of permanent policy?

Cash Accumulation (supplemental retirement income)
Guaranteed Death Benefit

How much does client want to contribute to plan on a monthly basis?

Desired Death Benefit:*

Riders:

Waiver of premium
Child Rider
Critical/Chronic Illness and/or LTC (available on permanent products only)

Case Design Notes – specific product, carrier, goal of case, etc. Please note if you discussed this case with an OCI sales representative or if you’re in competition with another carrier.

Common Health Conditions

Has the purposed insured been treated for and/or is taking medication for any of these conditions? (check all that apply)*

Alcohol Abuse (Current or past):

If yes, what was your course of treatment?

How does the Proposed Insured describe their condition?

How many times has the Proposed Insured been admitted to the hospital for this condition?

How many daily medications is the Purposed Insured taking?

In a typical year, how many asthma attacks does the Proposed Insured typically have?

None
1 to 6
7 to 12
13 or More

In the last year, how many times has the Proposed Insured been admitted (for one night or more) to the hospital due to an asthma attack?

When did you last have symptoms of asthma?

How does the Proposed Insured describe their condition?

How long ago was the Proposed Insured diagnosed with bipolar disorder?

How many times has the Proposed Insured been admitted to the hospital for this condition?

What was your last cholesterol reading?

How many different lipid lowering medications is the Proposed Insured currently taking?

How long ago was the Proposed Insured diagnosed with depression?

How many times has the Proposed Insured been admitted to the hospital for this condition?

How many daily medications is the Proposed Insured taking?

What type of Diabetes was the Proposed Insured diagnosed with?

What was your last A1C reading?

Does the Proposed Insured take prescribed medication for their Diabetes?

Yes
No

Is this current or past use?

Current
Past (over 2 years)

Treatment that the Proposed Insured accessed?

Date of last use?

Last blood pressure reading- Systolic

Last blood pressure reading- Diastolic

Number of medications taken by the Proposed Insured

What is the prescribed course of treatment?

Please elaborate on any of the above conditions or any medical condition not listed. Please provide dates, treatment, and outcome.

VERY IMPORTANT: Over 35% of life insurance cases are rated or declined. Eliminate the surprise for your client and increase your closing percentage by asking your client about any known health conditions. Specifically ask if they have diabetes, cardiac conditions, depression/anxiety, sleep apnea, or cancer.

List any prescription medications taken during the past two years. Please list purpose, dosage, and frequency.

Additional Pre-Underwriting Questions

In the past 10 years has the Proposed Insured had a DUI or DWI?

Yes
No

If yes, how long ago was the Proposed Insured charged with the offense?

Has the Proposed Insured had two or more moving violations in the past 2 years?

Yes
No

How many moving violations?

Has the Proposed Insured had their license suspended or revoked in the past?

Yes
No

If yes, how long ago?

Has the Proposed Insured been convicted of, or are they currently being charged with, a felony? Or currently on parole or probation?

Yes
No

In the past 10 years has the Proposed Insured had any of the following conditions?

How many times has the Proposed Insured been admitted to the hospital for ADD/ADHD?

How many medications is the Proposed Insured taking for ADD/ADHD?

Have you been treated for this condition in the last 12 months?

Yes
No

Is the Proposed Insured's atrial fibrillation triggered by alcohol use?

Yes
No

How long ago was the Proposed Insured's last episode of atrial fibrillation?

What type of autoimmune condition does the Proposed Insured have?

Rheumatoid Arthritis
Psoriatic Arthritis
Discoid Lupus
Systematic Lupus

What is the Proposed Insured's functionality with the condition?

How long ago was the Proposed Insured diagnosed with this disease/disorder? (excluding non-melanoma skin cancer)

How long ago was the Proposed Insured diagnosed with this disease/disorder?

What is the Proposed Insured's symptom frequency?

Chronic
Acute

When was your last colonoscopy?

Does the Proposed Insured take prescribed medication for the condition?

Yes
No

How long ago was the Proposed Insured diagnosed with this disorder?

Do any of these apply to the Proposed Insured? (ability to click multiple boxes- see screenshot)

Heart Attack
Angioplasty
Bypass
Valve Surgery

How many times has the Proposed Insured been admitted to the hospital for this condition?

Is the Proposed Insured currently receiving any government benefits, allowance or credits due to PTSD, or have they retired early due to this condition?

Yes
No

In total, how many months have you had off due to this condition in the last year?

Has the Proposed Insured's biological mother or father been diagnosed with Heart Disease, Cerebrovascular Disease, Cance or Diabetes at or before age 70?

Yes
No

If yes, which of the Proposed Insured parents?

Mother
Father
Both

Select all that apply

Heart Disease
Cerebrovascular Disease
Cancer
Diabetes

Has the Proposed Insured's biological sibling(s) been diagnosed with Heart Disease, Cerebrovascular Disease, Cancer or Diabetes at or before the age of 50?

Yes
No

How many of the Proposed Insured's siblings were diagnosed prior to age 50?

Select all that apply

Heart Disease
Cerebrovascular Disease
Cancer
Diabetes

Purpose of coverage?

If other, please list:

CAPTCHA

By clicking Submit, I certify all information is true and accurate to the best of my knowledge.