Welcome to Midwest Life Brokerage Associates Form Submission Page. We are so pleased that you've entrusted us to find you the best life insurance rate possible. Our staff is ready to assist you quickly and professionally find the biggest "Bang" for your important buck.

We are different than your local Home and Auto Insurance Agent. Check out what makes us different:
1) We are contracted with 60 Domestic Life Insurance Carriers
2) We are a Life Brokerage Operation, meaning we hold the contracts, and speak directly to underwriters on your behalf.
3) Our only business is Life Insurance!!! We are ready to assist you today.

Please complete this form below and we'll provide a quotation for your Individual coverage within a matter of hours. No medical forms or tests are required for the quote. This request should take just a few of your valuable minutes.

Fields marked with an asterisk* are required. Thank you for stopping by!

First Name Last Name Gender Male Female Postal Code State Alabama: ALAlaska: AKArizona: AZArkansas: ARCalifornia: CAColorado: COConnecticut: CTDelaware: DEFlorida: FLGeorgia: GAHawaii: HIIdaho: IDIllinois: ILIndiana: INIowa: IAKansas: KSKentucky: KYLouisiana: LAMaine: MEMaryland: MDMassachusetts: MAMichigan: MIMinnesota: MNMississippi: MSMissouri: MOMontana: MTNebraska: NENevada: NVNew Hampshire: NHNew Jersey: NJNew Mexico: NMNew York: NYNorth Carolina: NCNorth Dakota: NDOhio: OHOklahoma: OKOregon: ORPennsylvania: PARhode Island: RISouth Carolina: SCSouth Dakota: SDTennessee: TNTexas: TXUtah: UTVermont: VTVirginia: VAWashington: WAWest Virginia: SVWisconsin: WIWyoming: WY Day Phone Evening Phone E-Mail Address Month of Birth JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day of Birth 12345678910111213141516171819202122232425262728293031 Year of Birth 192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009 Desired Amount of Insurance $50,000$100,000$150,000$200,000$250,000$300,000$350,000$400,000$450,000$500,000$600,000$750,000$1,000,000$1,500,000$2,000,000$2,500,000$3,000,000$4,000,000$5,000,000$6,000,000$7,000,000$8,000,000$9,000,000$10,000,000unknown Desired Length of Coverage 10 year term15 year term20 year term25 year term30 year term35 year termCoverage to age 100 (UL) Would you consider a plan that Refunds your Premiums? Yes No Do you Currently use tobacco products? NoYes, CigarettesYes, Cigars (no cigarettes)Yes, Pipe, Chewing Tobacco or Gum (no cigarettes) Have you EVER used tobacco products? No, Never!Yes, but I have quit more than 12 months agoYes, but I have quit more than 24 months agoYes, but I have quit more than 36 months agoYes, but I have quit more than 60 months ago Approximate Height 4 Feet 6 inches4 Feet 7 inches4 Feet 8 inches4 Feet 9 inches4 Feet 10 inches4 Feet 11 inches5 Feet 0 inches5 Feet 1 inch5 Feet 2 inches5 Feet 3 inches5 Feet 4 inches5 Feet 5 inches5 Feet 6 inches5 Feet 7 inches5 Feet 8 inches5 feet 9 inches5 Feet 10 inches5 Feet 11 inches6 Feet 0 inches6 Feet 1 inch6 Feet 2 inches6 Feet 3 inches6 Feet 4 inches6 Feet 5 inches6 Feet 6 inches5 Feet 7 inches6 Feet 8 inches6 feet 9 inches6 Feet 10 inches6 Feet 11 inches Approximate Weight 120 lbs121122123124125126127128129130 lbs131132133134135136137138139140 lbs141142143144145146147148149150 lbs151152153154155156157158159160 lbs161162163164165166167168169170 lbs171172173174175176177178179180 lbs181182183184185186187188189190 lbs191192193194195196197198199200 lbs201202203204205206207208209210 lbs211212213214215216217218219220 lbs221222223224225226227228229230 lbs231232233234235236237238239240 lbs241242243244245246247248249250 lbs251252253254255256257258259260 lbs261262263264265266267268269270 lbs271272273274275276277278279280 lbs281282283284285286287288289290 lbs291292293294295296297298299300 lbs301302303304305306307308309310 lbs311312313314315316317318319320 lbs321322323324325326327328329330 lbs331332333334335336337338339340 lbs341342343344345346347348349350 lbs351352353354355356357358359360 lbs361362363364365366367368369370 lbs+ Has there been a significant change in weight in the past 12 months? Yes No Are your parents still alive? Yes, both are still aliveYes, 1 parent died before age 60Yes, 1 parent died before age 65Yes, 1 parent died before age 70Yes, 1 parent died after age 70No, both are deceased (youngest was under 60)No, both are deceased (youngest was under 65)No, both are deceased (youngest was under age 70)No, both died after the age of 70 Did either of your parents have Cancer? No, neitherYes, 1 parent had cancer before age 60Yes, 1 parent had cancer before age 65Yes, 1 parent had cancer before age 70Yes, 1 parent had cancer after age 70Yes, both parents had cancer (youngest before age 60)Yes, both parents had cancer (youngest before age 65)Yes, both parents had cancer (youngest before age 70)Yes, both parents had cancer, but after age 70 If so, at what approximate age? Did either of your parents have Cardiovascular history? No, neitherYes, 1 parent had cardiovascular hx before age 60Yes, 1 parent had cardiovascular hx before age 65Yes, 1 parent had cardiovascular hx before age 70Yes, 1 parent had cardiovascular hx after age 70Yes, both parents had cardiovascular hx (youngest before age 60)Yes, both parents had cardiovascular hx (youngest before age 65)Yes, both parents had cardiovascular hx (youngest before age 70)Yes, both had cardiovascular hx, but after age 70 If so, at what approximate age? Do you have a Personal Physician? No, I have never seen a doctorYes, I have a doctor, but only go when I need toYes, I have a doctor that I visit every 2 yearsYes, I have a doctor that I visit every year Have you ever had an elevated Cholesterol reading? Yes No Have you ever had an elevated Blood Pressure reading? Yes No Are you taking any prescription medicine? Yes No If so, what are you taking? - name and daily dosage Please describe your personal health & regular medication usage? Have you ever had a DUI/DWI or Reckless Driving charge? NeverYes, 1 DUI/DWI or Reckless Driving charges in the last 5 yearsYes, 2 DUI/DWI or Reckless Driving charges in the last 5 yearsYes, 3 or more DUI/DWI or Reckless Driving charges in the last 5 years Please describe your driving history No citations in the past 3 yearsNo more than 1 citation in the past 3 yearsNo more than 2 citations in the past 3 years3 or more citations in the past 3 years Have you ever had any drug or alcohol treatment? Yes No Are you involved in any PRIVATE (non-commercial) aviation? Yes No Do you participate in any hazardous activities? No, neverYes, Scuba DivingYes, Hang GlidingYes, Rock ClimbingYes, Auto RacingYes, Other Which carrier do you have your Auto/Home coverage with? Who is your Auto/Home agent? Preferred means of contact? PhoneE-Mail Preferred time of contact? ImmediatelyWeekday 9a-5pWeeknight 5p-9pWeekend 9a-12p Do you Currently have any life insurance Yes No If so, how much life insurance do you currently enjoy? With which insurance carrier do you have coverage? Comments: Image Verification Please enter the text from the image: [ Refresh Image ] [ What's This? ] Powered byEMF PHP Forms Quotes are for informational purposes only and do not constitute an offer of insurance. In order for any insurance to take effect, a fully completed application will need to be submitted and Paramedical tests will be required. Carrier Underwriting will ultimately determine if coverage is available for each independent risk.

	Midwest Life Brokerage
Kristopher T. Smith, President & CEO 1717 N. Naper Blvd. Suite 200 Naperville, IL 60563 Phone 630-428-7640