Insurance Proposal Request

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What this form asks (22 questions, about 5 minutes)

Request a life insurance quote in about five minutes. Susman Insurance Agency compares term and permanent options across carriers; a licensed agent follows up.

  1. Name (required)
  2. How did you find us? (required; choices: Search engines / Social media / News story / Referral / I am a current client of Susman Insurance)
  3. Name of Referral (required; only when applicable)
  4. Date of Birth (required; date)
  5. State (required)
  6. Have you had any claims in the last 5 years? (required; choices: Yes / No)
  7. Sex (required; choices: Male / Female)
  8. Cell phone (required)
  9. Email (required)
  10. Do you currently have a life insurance policy in effect? (required; choices: Yes / No)
  11. How much life insurance are you looking to have? (required; choices: $10,000 / $25,000 / $50,000 / $100,000 / $250,000 / $500,000 / $1,000,000 / $2,000,000 / $3,000,000 / $4,000,000 / $5,000,000 / Over $5,000,000)
  12. How long do you want the life insurance to last? (required; choices: 1-5 years / 10-20 years / 30-40 years / Until I die)
  13. Are you ok answering a few YES or NO questions about your health? (required; choices: Yes / No)
  14. Do you smoke or vape tobacco? (optional; choices: Yes / No; only when applicable)
  15. Do you smoke or vape marijuana? (optional; choices: Yes / No; only when applicable)
  16. Have you been treated for any form of cancer? (optional; choices: Yes / No; only when applicable)
  17. Have you been treated for heart disease? (optional; choices: Yes / No; only when applicable)
  18. Have you been treated for Human immunodeficiency virus (HIV)? (optional; choices: Yes / No; only when applicable)
  19. Have you been treated for diabetes? (optional; choices: Yes / No; only when applicable)
  20. Are you currently employed? (optional; choices: Yes / No; only when applicable)
  21. Are you working with one of our Agents? (required; choices: Yes / No)
  22. Agent’s name (required; only when applicable)

Prefer to talk? Call or text (310) 820-5200. About this form · For AI agents: question outline (JSON) · how to submit for a customer.