International Term Life "*" indicates required fields Here is what we need to know. To give you the most accurate quote on long-term international term-life (or AD&D) insurance, our carriers require the following information. Neither they, nor we, will bug you except to give you the quote you are looking for – If you’ve ever gotten an insurance quote before, you know that’s nice! Also, term-life policies are individual policies. Husband and wife must complete separate quote requests (Skype us at ‘goodneighborinsurance‘ if you have questions!) Name (First Name, Last Name) Email* If currently living in the USA: Your ZIP code Country of Residence For what City & Country will policy be in effect:* What other Cities/Countries will you be visiting/living in? Date of departure? Month Day Year Return date? Month Day Year Desired length of coverage: When would you like this policy to become effective: Month Day Year Amount of insurance (in U.S. dollars) First Choice:$100,000$150,000$200,000$250,000$300,000$350,000$400,000$450,000$500,000$550,000$600,000$650,000$700,000$750,000$800,000$850,000$900,000$950,000$1,000,000Amount of insurance (in U.S. dollars) Second Choice:$100,000$150,000$200,000$250,000$300,000$350,000$400,000$450,000$500,000$550,000$600,000$650,000$700,000$750,000$800,000$850,000$900,000$950,000$1,000,000Amount of insurance (in U.S. dollars) Third Choice:$100,000$150,000$200,000$250,000$300,000$350,000$400,000$450,000$500,000$550,000$600,000$650,000$700,000$750,000$800,000$850,000$900,000$950,000$1,000,000Other amount of coverage requested: A bit more about you:Gender Male Female Date of Birth* Month Day Year Height? (Indicate inches/cm) Weight (Indicate lbs./kg.) Country of Citizenship What kind of work do you do: Organization/Company: Highest Level of Education AchievedDid not complete K-12Completed K-12College – 2 yearsCollege – Undergrad degree / 4 yearsCollege – Master degree or above / 6 years or aboveTotal Annual Income From All Sources* Why do we ask for Education Level and Income? These help us determine the fairest pricing for every applicant, as higher levels of education and income may result in a discount to a person’s nationality or residence pricing. (Note that this will never result in a higher premium) What counts as income? This should be Annual Average Household Income from all sources. This means employment income, including a spouse’s income as well as any other regular income such as rent received or investment income, as long as you receive these each year.About your health:Have you been turned down for life insurance? Yes No When/Why were you declined: Under a doctor's present care for a medical condition? Yes No For what? Medication(s)? Have you had any of the following medical conditions? Yes No Cancer, Heart Disease/Attack, High Blood Pressure, Stroke, High Cholesterol, Diabetes, HIV / AIDS, Mental Illness If yes, please tell us who it is and describe Additional medical conditionsDo you use tobacco products? If "Yes", below please describe usage: Yes No Quantity? How often? Any further requests/comments?Lastly, how did you hear about us? We’re open 8:00-17:00 MST Monday-Friday. On work days we provide quotes within 24 hours, and usually much sooner than that. If your request is submitted over the weekend, we will get a quote to you before the end of the work day on Monday.PhoneThis field is for validation purposes and should be left unchanged. Δ
