Spouse's Information: (Leave Blank if you do NOT want Spouse Coverage)
Name of Spouse:
Enter Spouse's Birthdate:
Do You Smoke?:
Amount of Coverage Desired?
Type of Life Coverage Desired?
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, no-exam life, etc.
Years of Level Premium, if selecting term life.
List Any Health Problems:
Reason for Buying Life Insurance:
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Shuttleworth Insurance | 5811 Covington Road | Ft. Wayne, IN 46804 | Local Phone: 260-436-2580 | Fax: 260-436-3769