Life Insurance – Quick Quote Underwriting

    Thank you for stopping by our DropTicketLife.com Quick Quote system, powered by MWLBExpress. This short informal application will allow us to review a Life Insurance Prospects health history, submit it to Midwest Life Brokerage, and shop the case for your prospect -- all without completing a formal application or ordering any underwriting requirements. Taking 5 minutes to answer these questions may allow us to fast-track your application through Quick Quote underwriting process and give us tentative pricing from each responding carrier. Please be sure to answer ALL questions, and give details where required in the "Notes" field of each section.


    Prospect's Information -- Any Information identifying the client will NOT be given to the Carrier

    Client Name (required)

    Current Date of Birth (required)

    Gender (required)

    Height (Feet) (required)

    Height (Inches) (required)

    Total Current Weight, in pounds (required)


    Has the prospect's weight changed by more than 15 pounds in the past year?
    YESNO

    Has any application for life, health, disability or long term care insurance been declined, withdrawn, postponed, rated, modified, issued with exclusion rider, cancelled or non-renewed?
    YESNO


    Current Tobacco Usage (required)
    YESNO

    Current Marijuana Usage (required)
    YESNO


    Largest Amount of Life Insurance Death Benefit currently being considered for this application? (required)

    Current Amount of Individual Life Insurance Death Benefit currently Inforce? This does NOT include Group Life Insurance inforce. (required)

    Agent's Information

    Agent's Name:

    Agent's Phone Number:

    Agent's Email Address:

    Family History Information

    Does your Father have any history of heart disease, stroke, cancer or melanoma before his age 60? (required)
    YESNOUnknown

    Does your Mother have any history of heart disease, stroke, cancer or melanoma before her age 60? (required)
    YESNOUnknown

    Do any of your siblings have any history of heart disease, stroke, breast cancer, colon cancer, lung cancer, prostate cancer, ovarian cancer or melanoma before their age 60? (required)
    YESNOUnknownNo Siblings

    Please describe the issue any Family History "Yes" answer for Father, Mother or Siblings. Please list person, along with age diagnosed, diagnosis, and results of each? (If none, type NONE)

    Health History Information

    Type of Health Concern - Issue #1 (required)

    Diagnosis - Issue #1 (required)

    Age at Onset - Issue #1 (required)

    Treatment - Issue #1 (required)

    Type of Health Concern - Issue #2 (if needed)

    Diagnosis - Issue #2 (if needed)

    Age at Onset - Issue #2 (if needed)

    Treatment - Issue #2 (if needed)

    Type of Health Concern - Issue #3 (if needed)

    Diagnosis - Issue #3 (if needed)

    Age at Onset - Issue #3 (if needed)

    Treatment - Issue #3 (if needed)

    Physician's Information

    Have you seen a Physician in the last 5 years? (required)
    YESNO (If "No", skip to next section)

    Primary Physician's Name:

    Physician's Phone Number:

    Physician's City/State/Zip:

    Last Month/Year you saw this Physician?

    What was the reason you saw this Physician?

    What was the Final Result of this visit to this Physician?

    Please add any notes to "YES" answers for Physician's Information below. Also, please include notes below if you have multiple doctors (we'll need to know their Name, Address, Phone, as well as Date, Reason and Result of last visit for each Physician.

    Non-Medical Questions

    1) Does the Primary Proposed Insured intend to travel or reside outside of the United States or Canada within the next two years? *
    YES (Please explain below)NO (Move to Question 2)

    please list the country(ies), city(ies), date, length of stay, and purpose below:

    2) In the past 5 years, has the Proposed Insured participated in, or do you intend to participate in: any flights as a trainee, pilot or crew member; scuba diving; skydiving or parachuting; ultralight aviation; auto racing; cave exploration; hang gliding; boat racing; mountaineering; extreme sports or other hazardous activities? *
    YES (Please explain below)NO (Move to Question 3)

    Please list the activity, the date you last participated, where you participated, and if you have plans to participate in the future below:

    3) Has the Proposed Insured submitted an application for life insurance to any other company within the past 90 days or begun the process of filling out an application? *
    YES (Please explain below)NO (Move to Question 4)

    Please list the company name, amount applied for, and purpose of insurance below:

    4) Have you ever had a life or disability insurance application modified, rated, declined, postponed, withdrawn, canceled, or refused for renewal? *
    YES (Please explain below)NO (Move to Question 5)

    Please list the date and reason below:


    5) Have you ever filed for bankruptcy? *
    YES (Please explain below)NO (Move to Question 6)

    Please list the chapter filed, date, reason, and discharge date below:

    6) In the past FIVE years, has the Proposed Insured been charged with or convicted of any driving violations to include driving under the influence of alcohol or drugs? *
    YES (Please explain below)NO (Move to Question 7)

    Please list the date, state, license # and specific violation below:


    7) Has the Proposed Insured ever been convicted of or pled guilty or no contest to a criminal offense or currently have any felony or misdemeanor charge pending? *
    YES (Please explain below)NO (Move to Question 8)

    Please list the date, state, license # and specific violation below:

    8) Is the Proposed Insured an active duty service member of the US Armed Forces, a member of the National Guard or an active reservist of the US Armed Forces, or a dependent of an active duty service member of the US Armed Forces? *
    YES (Please explain below)NO (Move to Question 9)

    Please provide Pay Grade, Rank, and any known foreign assignments below:

    9) Does the client have any surgical procedures that have been discussed but not completed?

    10) Does the client take any medication on a regular basis?


    Acceptance of Terms of Use

    PLEASE CHECK THIS BOX --> By checking this box, you agree that as the Proposed Insured, you believe each of these answers and details to be true and complete to the best of your knowledge and belief. The results of this quick quote will be non-binding and based solely on the information you have provided. A final underwriting decision will be made after receipt, review, and assessment of a formal application, age and amount requirements, any interim Attending Physician Statement(s), and any required facultative reinsurance review. You also understand that any misrepresentation contained in this submission and relied on by the company may be used to reduce or deny a claim or void the policy if: (1) such misrepresentation materially affects the acceptance of risk, and/or (2) the policy is within its contestable period. Finally, you agree to hold harmless all parties associated with this application for life insurance, including but not limited to the agent, brokerage operation, application processing center, and carrier. *

    Type your Full Name below, and that will represent your E-Signature. (required)

    We appreciate your business, and look forward to assisting you in completing this life application and getting coverage inforce as soon as possible.

    Thank you for your time and attention!