Request a Quote

If you are interested in selling a life insurance policy, please call us at (973) 275-1110 or fill out the form below. Not all fields are required; just give us as much information as possible.


Name *

Address *

Phone number *

Email address *

Relationship to the insured? *




Date of birth (mm-dd-yyyy)

Sex:  male female

Is the insured a:  smoker non-smoker

Does the insured live alone?  yes no

Does the insured person require assistance with Activities of Daily Living?  yes no

Is the insured person currently employed?  yes no

Tell us a little about the policy you are interested in selling

What type of policy is it (i.e. Universal Life, Whole Life, Survivorship Universal, Term)?

What is the face value (death benefit) of the policy?

How much are the annual premiums?

When was this policy originally purchased (or approximately how long has it been owned)?

Does the insured person have any of the following?

Disease or disorder of the heart including high blood pressure, atrial fibrillation, irregular pulse or other cardiac arrhythmia, heart attack, coronary artery disease, chest pain, angina, valve disease or other hear disorder?  yes no
Circulatory or blood vessel disorder including stroke, TIA (mini-stroke), aneurysm, arterial blockage in the neck, abdomen or legs, venous disease such as blood clots, thrombosis, embolism or any other?  yes no
Cancer tumor or malignancy?  yes no
Any immune system disorder?  yes no
Disease or disorder of the digestive system including diabetes, liver disease, colon, intestinal, stomach disorder or any other?  yes no
Infectious disease (other than common colds and flu) including hepatitis, pneumonia, sexually transmitted disease, shingles or any other?  yes no
Disease or disorder of the lungs or respiratory system including asthma, emphysema, COPD, chronic bronchitis, shortness of breath or any other?  yes no
Genitourinary problems including disease or disorder of the genitalia, breasts, prostate, bladder, kidney or any other?  yes no
Abnormality of the blood and platelets including anemia, high cholesterol or any other?  yes no
Bone or joint abnormality, paralysis, trauma, injury or physical impairment, including problems with balance or walking?  yes no
Neurological disorders including Parkinson's disease, multiple sclerosis, loss of consciousness, convulsions or epilepsy, loss of vision, loss of hearing, neuropathy, chronic pain or any other?  yes no
Mental or nervous disorder including memory or cognitive impairment, dementia, psychiatric disorder or any other?  yes no
Have you ever been treated for alcohol or drug abuse, or told by a physician or practitioner to reduce or eliminate alcohol or drug use?  yes no
Have you ever been diagnosed with, been treated for, had surgery or are you currently being treated for any other disease or disorder not previously given?  yes no

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