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Diversified Brokerage Specialists, Inc. > Request a Quote

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Agent Name*
First Last
Phone*
Email*
State*
Client #1
Date Of Birth
Month
Day
Year
Sex
- Male
- Female
Underwriting Class*
Nicotine/Marijuana
- NO NICOTINE/MARIJUANA
- cigarettes
- pipe
- cigar
- chewing tobacco
- e-cig/vapor
- marijuana
Please be specific as it will help us to determine the most competitive product! Select all that apply!
Cigar Usage
- 1 per month
- 2 - 4 per month
- 5+ per month
Health Considerations/Medications
Client #2
Date Of Birth
Month
Day
Year
Sex
- Male
- Female
Underwriting Class*
Nicotine/Marijuana
- NO NICOTINE
- cigarettes
- pipe
- cigar
- chewing tobacco
- e-cig/vapor
- marijuana
Please be specific as it will help us to determine the most competitive product! Select all that apply!
Cigar Usage
- 1 per month
- 2 - 4 per month
- 5+ per month
Health Considerations/Medications
Please include, the date of diagnosis, the diagnosis, treatment and medications
Client State
Writing State
Proposal Type
select an insurance type
Life Insurance Products
Face Amount
Length of Term
- 10 Year
- 15 Year
- 20 Year
- 25 Year
- 30 Year
Is there a 1035 or Lump Sum?
- Yes
- No
Amount of 1035/Lump Sum
Disability Product Type
Occupation/Duties
Income
In Force Disability Coverage
- Yes
- No
Description of In Force Coverage
Expenses
Amount of Coverage
Benefit Amount to Illustrate
- Maximum
- Specified
Specified Benefit
Benefit Period
- 2 Year
- 5 Year
- 10 Year
- To Age 65/67
STD Benefit Amount
- Maximum
- Specified
STD Specified Benefit
LTC Coverage Type
- Traditional Long Term Care
- Asset Based Long Term Care
Elimination Period
- 30 Days
- 60 Days
- 90 Days
Benefit Period Period
- 2 Yr
- 3 Yr
- 4 Yr
- 5 Yr
Inflation Options
- NONE
- 3% Compound
- 5% Compound
Monthly Benefit Amount
Please enter a number from 0 to 15000.
Premium Options
- Single Pay
- 10 Pay
- 20 Pay
- Lifetime pay
Source of Funds
- Qualified Money
- Non-Qualified Money
Specify a BENEFIT or Specify a PREMIUM
Please enter a number from 1 to 1000000.
Funding Source
- Qualified
- Non-Qualified
Product Type
- Single Premium Deferred
- Flexible Premium Deferred
- Single Premium Immediate
Single Premium Deferred Annuity Deposit
Please enter a number from 1 to 10000000.
Flexible Premium Deferred Annuity Deposit
- Annual
- Monthly
Deposit Amount
Please enter a number from 1 to 100000.
Single Premium Immediate Deposit
Please enter a number from 1 to 10000000.
Date of Deposit
MM slash DD slash YYYY
Date of Initial Benefit
MM slash DD slash YYYY
Payout Type
- Life Only
- Life and Years Certain
- Year Certain Only
- Installment Refund
Number of Years (If Applicable)