Current or Past Medical Problems
At TermLifePros we specialize in helping people who do not qualify for Preferred Plus rates. We have experience at placing cases for clients with medical issues that may have prevented them from buying term life insurance in the past. Our relationships with the key underwriters allows us to get better offers on these types of cases. Whether you are a diabetic, or have had heart problems, been diagnosed with cancer, or any other number of ailments we have the experience and knowledge to get you term life insurance for a lot less than you might think.

Because of this the online quotes are not always the lowest possible available. We encourage you to use our online quoting system as a reference, but to get the most accurate quote we suggest filling out the short form below so one of our agents can provide you with an accurate quote. Upon completing this form we will also give you quotes for the different health ratings to give you an idea of what to expect.
* = Required Field
First Name: *
Last Name: *
Date of Birth: *
Sex: *
Height:  Weight *
Marital Status:
Spouse's First Name:
Home Address:
  City
  *  Zip
Home Phone: *
Work Phone:
Best Time to Call:
E-Mail Address: *
Current Occupation:
Amount of Insurance: *
Length of Coverage: *
Are you a Tobacco or Nicotine User? *
Have you previously been rated or declined for life insurance?
 Yes   No
Has any member of your family died before the age of 60, or had any serious medical problems?
 Yes   No
If so please explain:
  
Health Problems:
List any medications taken & the amounts:
  
Additional remarks/comments about your health history: