Key Person Quote Re... | Source Brokerage

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Agent First/ Last Name*

Agent's Email*

Agent's Phone Number*

Client First/ Last Name*

Client's Date of Birth*

Month

Day

Year

Client's Sex*

Male

Female

Tobacco Use (All Nicotine Products)*

Yes

No

Quit within 12 months

Client's State of Residence*

Client's Occupation (Industry and Title/Position)*

Description of Client's Occupational Duties*

Length of time in occupation*

Is your client self-employed?*

Yes

No

If your client is self-employed, how long?

Less than one year

Less than two years

2+ Years

Does Your Client Have Existing Key Person Coverage?*

Yes

No

(If Applicable) If your client's coverage is an individual key person policy, what is their monthly benefit amount, benefit period, and elimination period?

Client's Taxable Income *

Desired Elimination Period*

90 Days

180 Days

365 Days

730 Days

Desired Benefit Period*

Lump Sum

Combo (Lump Sum and Monthly Benefit)

List any medical impairments (include medications, dates and client build).*

I understand this is only a preliminary quote and approval may change during underwriting.

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LOCATION

OPENING HOURS

Email: quotes@sourcebrokerage.com
Phone: 888.543.3634

13650 Fiddlesticks Blvd. #202-177, Fort Myers, FL 33912

Mon - Fri: 9am - 6pm est.

Saturday: Closed

Sunday: Closed

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Source Brokerage, LLC of Fort Myers, Florida, founded in 1992, is independently owned and operated and is not affiliated with the Indianapolis-based Source Brokerage acquired by Simplicity Group

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