Longyear Insurance Company - Where peace of mind meets endless protection

Get a Quote Today

First Name*

Last Name*

Date of Birth*

Beneficiary or Beneficiaries for Coverage*

Beneficiary relation to proposed insured*

Smoker*

Yes

Current Height & Weight*

Any Major Surgeries in Last 5 Years? If yes what?*

Any DUI's or Felonies? If so what?*

List of Current Medications (What they are used for is fine)*

Please indicate if you have been diagnosed with or are currently experiencing any of the following conditions: Heart attack, stroke, TIA (mini stroke), cancer, stents, diabetes diagnosed before 45, diabetes diagnosed after 45, taking insulin for diabetes, neuropathy, hypertension, lupus, rheumatoid arthritis, asthma, COPD, thyroid disease, anxiety/depression, kidney disease, liver disease, HIV, hepatitis A, hepatitis B, hepatitis C.*

Household Monthly Income*

Individual #1 Monthly Income

Individual #2 Monthly Income

Do you have any debt apart from the home? If so what?*

Current Mortgage Balance (if applicable)

Monthly Mortgage Payment*

Any assets that could replace your income like 401k, IRA ect... If yes what and how much?*

Do you currently have any other forms of life insurance? If yes what and how much?*

Email*

Phone Number*

Do you have a specific price range you are trying to stick between?

Are you looking for temporary (term) or permanent coverage (whole)

Any other comments or concerns:

Quotes are subject to approval by the insurance carrier and may change based on information in the MIB report*

Get a Quote Today

Book Appointment