Pg 2 of 2: 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!) Can you tell us a little more?First NameLast NameEmail* Do you want us to call you? (xxx)xxx-xxxxIf currently living in the USA: Your ZIP codeIf currently overseas: City and Country where you resideFor what City & Country will policy be in effect:*What other Cities/Countries will you be visiting/living in?Date of departure? MM DD YYYY Return date? MM DD YYYY Desired length of coverage:When would you like this policy to become effective: MM DD YYYY Annual Income: (Required)*Amount of insurance (in U.S. dollars): You may check up to 3 for quotes. $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $500,000 $600,000 $700,000 $800,000 $900,000 $1,000,000 Other (indicate below) Maximum allowed 10 times your annual income.Other amount of coverage requested:A bit more about you:GenderMaleFemaleYour Age Date of Birth MM DD YYYY Height? (Indicate inches/cm)Weight (Indicate lbs./kg.)Are you a U.S. Citizen?*YesNoIf no, your citizenship:What kind of work do you do:Organization/Company:About your health:Have you been turned down for life insurance?YesNoWhen/Why were you declined:Under a doctor's present care for a medical condition?YesNoFor what? Medication(s)?Have you had any of the following medical conditions?YesNoCondition(s) Cancer Heart Disease/Attack High Blood Pressure Stroke High Cholesterol Diabetes HIV / AIDS Mental Illness If yes, please tell us who it is and describeAdditional medical conditionsDo you use tobacco products? If "Yes", below please describe usage:YesNoQuantity? 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.We send out a quarterly helpful, money-saving e-bulletin, as well as updates, to keep you up-to-date regarding changes to policies, explain new benefits, as well as help you save money and stay safe while traveling. If you do not wish to receive our quarterly newsletter, you can say so here, or you can wait and unsubscribe at any time by using the link provided at the bottom of each newsletter. Rest assured - We never share or sell our lists. Ever.Get the e-Bulletin 4X a year!YesNoPhoneThis field is for validation purposes and should be left unchanged.