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Request a Quote For Individual Insurance

* Required

Types of Insurance

Life Insurance / Accidental Death and Disability
Personal Accident
Long Term Disability
Critical Illness

Application Contact Information

Prefix:

* First Name:

* Surname:

* Address 1:

Address 2:

* City:

* State / Province:

* Zip / Postal Code:

* Country:

* Citizenship:

* Country of Residence:

* Telephone:

Fax Number:

* E-mail:

Date of Birth:

* Gender:

* Smoker:

Yes No

* Height:

* Weight:

 

Occupation Information

* Position:

* Salary (Base, Bonuses, Commissions):

$

* Length of Employment:

* Describe your work duties:

* Is your occupation 100% office based?

Yes No
If no, then what percentage of the time do you spend in the field?
%

* Do you participate in any hazardous activities? (Parachuting, Jet Skiing, Auto Racing, Scuba Diving, Aircraft Pilot, etc.)

Yes No

* Do you participate in any organized or unorganized competitive sports? (Tennis Teams, Rugby, Football, etc.)

Yes No

* Do you travel internationally?
Yes No
If yes, the identify the countries visited, amount of time and purpose of the visit:

 

Country

Amount of Time

Purpose of Visit

1

2

3

4

5

 

Additional Application Information (Family Members)

How many family members?

1.)

* Name

* Date of Birth

* Relationship

* Citizenship

 

* Resident Country

* Occupation

* Type of Coverage

* Benefit Amounts

2.)

* Name

* Date of Birth

* Relationship

* Citizenship

 

* Resident Country

* Occupation

* Type of Coverage

* Benefit Amounts

3.)

* Name

* Date of Birth

* Relationship

* Citizenship

 

* Resident Country

* Occupation

* Type of Coverage

* Benefit Amounts

4.)

* Name

* Date of Birth

* Relationship

* Citizenship

 

* Resident Country

* Occupation

* Type of Coverage

* Benefit Amounts

5.)

* Name

* Date of Birth

* Relationship

* Citizenship

 

* Resident Country

* Occupation

* Type of Coverage

* Benefit Amounts

 

Currency Information

Select the preferred currency for policy illustration, benefit payment and premium payment. Note: In some countries the options are restricted due to local laws.

Policy Illustration:

USA Dollar
UK Pound Sterling
Euro
Swiss Franc
Japan Yen
Canadian Dollar

Benefit Payment:

USA Dollar
UK Pound Sterling
Euro
Swiss Franc
Japan Yen
Canadian Dollar

Premium Payment:

USA Dollar
UK Pound Sterling
Euro
Swiss Franc
Japan Yen
Canadian Dollar

 

Life Insurance

* Death Benefit:

$

* Accidental Death & Dismemberment Benefit:

$

* Term Coverage:

Yes No

* Term Length:

* Conversion Rider:

Yes No

* Permanent Coverage:

Yes No

* Whole Life:

Yes No

* Universal Life

Yes No

* Variable Life:

Yes No

Target Premium Amount:

$

* Waiver of Premium Rider:

Yes No

Special Provisions:

* Survivorship Policy:

Yes No

* First to Die Policy:

Yes No

* Do you have additional life insurance in place?

Yes No

Policy Owner:

Beneficiary:

Purpose of the insurance:

* Payment Method:

 

Personal Accident

* Benefit:

$

* Lump Sum Death Benefit or Annuity?

$

* Lump Sum Permanent Disability or Annuity?

$

* Benefit for Temporary Disability?

Yes No

* Daily Hospital Benefit?

Yes No

* Medical Expenses?

Yes No

* Payment Method:

 

Long Term Disability

* Monthly Benefit:

$

* Percentage of Income Covered:

%

* Benefit Period:

* Elimination Period (in days):

* Partial Disability:

Yes No

* Own Occupation:

Yes No
Period:

* Earnings Recovery:

Yes No

* Payment Method:

* Inflation Rider:

Yes No

* War Rider:

Yes No

* Special Purpose Coverage?

 

Critical Illness

* Benefit:

$

* Lump Sum:

Yes No

* Payment Method:

   
 
   

PHONE: +1-866-510-0149

International Insurance & Investments LLC

1725 Washington Rd. · Suite 406
Pittsburgh, PA. 15241 USA

International Insurance & Investments LLC is licensed in the European Economic Area, Switzerland, The United Kingdom and the United States of America. In the USA, the firm is licensed in 17 states. In the United Kingdom, the firm is authorized and regulated by the Financial Services Authority # 315054.


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ALL RIGHTS RESERVED.
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