Complete our fast and easy underwriting questionnaire to receive a preliminary offer in 48-hours or less.

 
Agent Information
* Agent:
* Phone:
 
Address:
 
* Fax:
* Email:
 
 
 
Client Information
 
* First Name:
 
Occasional Tobacco User:
Yes No
 
* Last Name:
 
* Date of Birth:
mm dd yyyy
 
* Insurance Amount:
 
* Sex:
Male Female
 
Plan of Insurance:
Term UL SUL
 
Height:
 
 
Additional Insured's Name (only if applying for Survivor UL)
 
 
Weight (lb):
 
 
Other Companies Actions
Company:
Action:
Date:
mm yy  
mm yy  
mm yy  
 
 
Click the box next to the impairment(s) below which most closely apply to your client. After selecting the impairment(s) select NEXT to go to questions that will help us provide the most accurate offer. Remember, you may choose multiple impairments.
                     
Cancer
Driving
Hepatitis C
Stroke
Depression
 
Drug/Alcohol
 
Obesity
 
Tobacco
Diabetes
 
Heart Disease
 
Sleep Apnea
 
Other
 

Comments/Explanation:

*indicates required field

 


Home | Annuities | Life Insurance | Impaired Risk Life | Term Life Quotes
Tools/Calculators
| Forms | Downloads |
Your Online Selling System

Circle of WealthMarketing Tools | Password Information | Calendar of Upcoming Events
Anti-Money Laundering Training |  Agent E&O Coverage |CE Credits & Agent Training
Disability Income | Get Contracted Online | Contact Us

   For more information ...

Call us - 800-843-3057

Fax us - 800-692-6932

e-mail us - robb@oxbowmkt.com

Copyright 1997-2011  Oxbow Marketing Company All Rights Reserved