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UNIVERSAL LIFE QUOTE REQUEST

Fill out this secure form to get your free, no-obligation quote for Universal Life Insurance from Wescom Insurance Services. If you have any questions as you’re filling out the form, please feel free to call Wescom Insurance Services at 1-888-4WESCOM (1-888-493-7266), ext. 1080, Monday through Friday from 8:30 a.m. to 5 p.m. PST.


Your Information

First Name:
Last Name:
Gender:
Date of Birth:
Email:
Phone:
Best time to call:
Address:
City:
State:
Zip:
Weight:
Height:
What Benefit Amount would you like?
Please Select One No Yes
Do you smoke or use tobacco?
Have you ever been rated or declined for life insurance?
In the past 3 years, have you flown as a pilot, co-pilot, or crew member of an aircraft or intend to in the next 2 years?
In the past 3 years, have you participated in scuba diving, hang gliding or racing or intend to participate in the next 2 years?
Has your weight changed by 10 Pounds or more in the last year?
Are you now taking medication or are you under treatment by a medical professional?
Do you have any medical history or condition that you think may affect your insurability (e.g., high blood prussure, diabetes, etc.)?
Is there other information about you that may affect your insurability (for example, motor vehicle racing, hazardous activities, treatment for substance abuse, and so forth)?
Please explain each item for which you answered YES to
How did you hear about Wescom Insurance Services?
Additional Information: