Free No Cost FEGLI Replacement Quote
Your Postal insurance will increase over 300% over your career.  If you are relatively healthy- it is always a good choice to replace your Postal insurance with coverage that never increases in price and in some cases gives your money back if you do not die.   Please take a few minutes to fill out the form below.  If you are not sure about something you can leave it blank.   The cost of not checking can mean leaving your loved ones with no life insurance at all.

Once you have submitted the information a certified consultant will contact you to confirm the information and give you an idea as to how we can help you. There is no cost for this service to you.
State :
Amount of Insurance Requested :
Circle Desired Duration(s) For Quote :
10 15 20 30  Year Guaranteed Term
15 20 30  Year Term With Return of Premium
Sex :
Male Female
Smoking Status :
Yes No
Health :
Standard Standard Plus
Preferred Preferred Plus
Birth Date :
Premium Mode :
Annual Monthly
Quarterly Semi-Annually
1. Health Analyzer:
Your weight - pounds :
Your height :
feet     Inches
2. Current/Past/Smoking/Tobacco use : Check each tobacco product that you have EVER smoked or used
Cigarettes
Cigars
Pipe
Chewing Tobacco
Nicotine Patches or Gum
 3. Blood Pressure : Have you ever been treated for or taken medication for high blood pressure?
If yes, What is your systolic pressure :
If yes, What is your diastolic pressure :
4. Cholesterol : Have you ever taken medication for high cholesterol?
If yes, What is your cholesterol level :
If yes, What is your HDL ratio :
 5. Driving : Have you ever had a drivers License?
Have you ever been convicted of drunken driving (DUI/DWI) :
Have you ever been convicted of reckless driving :
Have you ever been revoked or suspended :
Have you ever had more than one accident :
Please indicate the TOTAL number of moving violations/tickets(ie. not parking tickets)
that you have received in each of the last time periods:
during the last 6 months :
during last year, more than 6 years :
during the last 2 years, more than 1 year :
during the last 3 years, more than 2 years :
during the last 5 years, more than 3 years :
 6. Family History :
  Family related deaths :
Please indicate the total number of family members (parents or siblings) who have died from cardiovascular disease.

(heart attack and strokes), cancer, diabetes or kidney disease before the age of 70:

Family related occurrence of disease :
Not including who died, please indicate the total number of family members(parents or siblings) who have contracted cardiovascular disease (heart attacks and strokes), cancer, diabetes or kidney disease before the age of 70.
 7. Medications :
Please list any prescriptions you are currently taking below:
Prescription:    Milligrams:    Reason For Prescription:
How Often Do You Take The Prescription:
Prescription:    Milligrams:    Reason For Prescription:
How Often Do You Take The Prescription:
Prescription:    Milligrams:    Reason For Prescription:
How Often Do You Take The Prescription:
Prescription:    Milligrams:    Reason For Prescription:
How Often Do You Take The Prescription:
 8. Doctor Information :
Please list your current family Doctor: Phone Number:
 9. Insured Information :

PROPOSED INSURED

Full Name :
First : Middle : Last :

NOTICE : type letters ONLY in name. no hyphens or apostrophes.

Street Address :
City : State : Zip code :
Gender : Home phone : ex.555-555-5555 Occupation :
Date of Birth : Work Phone : ex.555-555-5555 Annual Income :
Birth Place : Cell Phone : ex.555-555-5555 Net Worth :
SSN : Drivers License # : Household Income :
DL State :         
Email Address :
Fax :
PRIMARY BENEFICIARIES If name or relationship more than 25 characters please continue in Remarks box

NAME

SSN/Tax ID

Gender

DOB

Relationship
(dd/mm/yyyy)
(dd/mm/yyyy)
(dd/mm/yyyy)
(dd/mm/yyyy)
(dd/mm/yyyy)

IF TRUST

Name : Tax ID # :
Trustee : Date of Trust :
ADDITIONAL COMMENTS & REMARKS
 
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