Joseph Kovacs Insurance Brokers - Life Insurance Quote Form

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LIFE INSURANCE
QUOTE FORM

Great News!!
A combination of people living longer and the stiff competition for the term life insurance market have
caused the Term Insurance rates to drop lower than ever!!

Monthly Rates - Male Non-Smoker *

Amount		$100,000	$250,000	$500,000	$1,000,000
Age	25	$ 11.52	$ 20.25	$ 36.00	$ 66.60
	35	$ 12.33	$ 22.28	$ 38.70	$ 71.10
	40	$ 14.94	$ 28.13	$ 49.50	$ 92.70
	45	$ 18.90	$ 37.80	$ 70.20	$ 135.00
	50	$ 25.47	$ 52.43	$ 97.20	$ 187.20
	55	$ 39.60	$ 83.25	$ 159.75	$ 313.20

Monthly Rates - Male Smoker **

Amount		$100,000	$250,000	$500,000	$1,000,000
Age	25	$ 14.94	$ 27.23	$ 47.70	$ 88.65
	35	$ 15.48	$ 28.58	$ 50.40	$ 94.05
	40	$ 18.54	$ 36.23	$ 65.70	$ 124.65
	45	$ 26.91	$ 57.15	$ 107.55	$ 208.35
	50	$ 38.34	$ 85.73	$ 164.70	$ 322.65
	55	$ 53.73	$ 124.20	$ 241.65	$ 476.55

* Based on Ten-Year Renewable & Convertible Term Insurance. This product is convertible to permanent insurance without medical examination.

** Smoker's Choice receive non-smoker rates for four years. If you stop smoking you keep the same low rate. If you don't, you will go to smoker rates, based on your age four years earlier. Either way you save!

To receive a quote for life insurance please complete the following form and one of our brokers will contact you as soon as possible.
(Ontario residents only please.)

Contact Information:

Name:
Street Address:
City:
Postal Code:
Phone Number:
Fax Number:
E-mail:

What is your gender?

What is your date of birth? (yy/mm/dd)

Do you smoke cigarettes? Yes No
Do you smoke ONLY cigars or a pipe? Yes No

How is your health?

Exellent	Not undergoing treatment or taking medications
Good	Medications for minor ailment.
Fair	Suffering from a condition such as asthma, non-insulin diabetes or high blood pressure
Poor	Suffering from a major condition such as heart, lung, kidney or liver condition, a stroke or debillitating muscle disease.

Amount of insurance required: $

Type of insurance:

Term Insurance

Yearly Renewable
5yr
10yr
15yr
20yr
to age 65
to age 75
to age 100

Other Insurance

Universal Life

Whole Life

Lifetime Payments

Quick Pay

When should we contact you?:

How should we contact you?

E-mail Phone Fax Mail

Thank you for filling out our online quote. Please allow a few days for a response. You can now hit the submit button below to send the information or the reset button to clear the form.

JOSEPH KOVACS INSURANCE LIMITED
48 Front St. E., P.O. Box 7 Strathroy, Ontario N7G 3J1

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