"Your Local Trusted Choice Agency"
Call us at 480-264-6226   

 
Do you need a detailed online quote? Then choose Auto, Homeowners or Health below, and fill out a short form to get your quote.

"Quality Insurance Services Since 2002"

Get a Quote

Start a Life Insurance Quote



You are only required to complete the first section of this form in order to receive a response from an agent. Any other information you would like to enter on this form is optional.


Personal Information


Name Email Address
Address Day Phone
City Night Phone
State Best Time to Call    AM    PM
Zip
Preferred Contact Method   Email    Phone


Personal Information Please enter information below for all to be covered.
 
Self
Spouse
Child #1
Child #2
Child #3
Name:
Self
Date of
Birth:
Sex:
M   F
M   F
M   F
M   F
M   F
Marital Status:
M   S
M   S
M   S
M   S
M   S
Occupation:
Height:
ft.   in.
ft.   in.
ft.   in.
ft.   in.
ft.   in.
Weight:
lbs.
lbs.
lbs.
lbs.
lbs.
Have you (they) had
any of the following
health conditions:		 Heart
Cancer
Diabetes
HBP		 Heart
Cancer
Diabetes
HBP		 Heart
Cancer
Diabetes
HBP		 Heart
Cancer
Diabetes
HBP		 Heart
Cancer
Diabetes
HBP
Please enter information below about TOBACCO usage for all to be covered.
Have you (they)
ever used tobacco or
nicotine products?:		 Never
Present
Quit**		 Never
Present
Quit**		 Never
Present
Quit**		 Never
Present
Quit**		 Never
Present
Quit**
Type of
Tobacco used?:		 smokeless
cigar
cigarette
pipe
patch/gum		 smokeless
cigar
cigarette
pipe
patch/gum		 smokeless
cigar
cigarette
pipe
patch/gum		 smokeless
cigar
cigarette
pipe
patch/gum		 smokeless
cigar
cigarette
pipe
patch/gum
Packs per day:





# of yrs smoked:
**Quit -- Please enter information if any to be insured are FORMER TOBACCO users.
**Quit Month/Year:
Packs per day:
Years smoked?:


Individual Histories Please list any individual histories on each person to be covered.
Self
Is person to be insured currently on any prescription medications for
ongoing health conditions?Yes  No     If yes, please list below.
Also, please DISCLOSE any and all health conditions you have (or had in the past):
Spouse
Is person to be insured currently on any prescription medications for
ongoing health conditions?Yes  No     If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #1
Is person to be insured currently on any prescription medications for
ongoing health conditions?Yes  No     If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #2
Is person to be insured currently on any prescription medications for
ongoing health conditions?Yes  No     If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #3
Is person to be insured currently on any prescription medications for
ongoing health conditions?Yes  No     If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):


Life Coverages
 
Self
Spouse
Child #1
Child #2
Child #3
Amount of
Coverage:
$
$
$
$
$
Type of
Coverage:		 Term
Whole
Universal		 Term
Whole
Universal		 Term
Whole
Universal		 Term
Whole
Universal		 Term
Whole
Universal
Term
Length (Optional)
Disability
Income:
Y   N
Y   N
N/A
N/A
N/A
Long Term
Care:
Y   N
Y   N
N/A
N/A
N/A


Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional children or other information where there was not enough space, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

Submission of quote request form to this agency does not constitute a binding confirmation of new or revised insurance coverage.

Lets get social

Send us a message

Scott Taylor Metlife Owner of the Year