Life Insurance – JJ Insurance Agency

On-Line Life Insurance Quote Form

Complete our short Minnesota life insurance information form and we will be in touch soon.

Personal Information

Enter your full name:

Company name:

Street address:

City:

State:

Zip Code:

Email (required):

E-Mail again for accuracy:

Phone:

Are You Married?
Unusual Activities? (If you engage in unusual activities such as scuba diving, airplane flying, rock climbing, etc., list them here.)

Currently Insured?
If currently covered list carrier, # of years covered, and type of coverage

Underwriting Information

Name of Proposed Insured:

Enter Insured's Birth date:

Sex:

Do You Smoke?:

Height:

Weight:

Spouse's Information:(Leave Blank if you do NOT want Spouse Coverage)

Name of Spouse:

Enter Spouse's Birthdate:

Sex:

Do You Smoke?:

Spouse Height:

Spouse Weight:

Coverages

Amount of Coverage Desired?

Type of Coverage (Term, Universal life, Other):TERM = Pays death benefit only - This is lowest cost for coverage.UNIVERSAL LIFE = Has savings aspect in addition to providing death benefit.OTHER = Would be mortgage protection, whole life, etc.

Years of Level Premium:

List Any Health Problems:

Reason for Buying Life Insurance:

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Thank you for filling out this form COMPLETELY! We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me a Quote NOW!