Skip to content
Home
Protection Plans
About Us
About Us
Leave A Review
Refer Friends & Family
Our Blog
Coverages
Personal Insurance
Commercial Insurance
Life Insurance
Farm Insurance
Address:
6 N Division St,
Du Quoin, IL 62832
Phone:
(618) 790-9400
Email:
info@eclipseinsure.com
Home
Protection Plans
About Us
About Us
Leave A Review
Refer Friends & Family
Our Blog
Coverages
Personal Insurance
Commercial Insurance
Life Insurance
Farm Insurance
Client Services
Get A Quote
Get A Quote Here
Menu
Life Insurance Quote
1
Contact Info
2
Auto
3
Who is filling out this form?
Client
Agent
How did you hear about us?
Billboard
Cross-Sale
Erie
Facebook
Google
Natural Market
Popcorn Bag
Referral
Bill Kemme – State Farm
Gershman Mortgage
What other way did you hear about us?
Who Referred You?
First
Last
Contact Information
Primary Insured's First & Last Name
*
First
Last
Home Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Insured Cell Phone Number
*
Primary Insured Email
*
Primary Insured Gender
*
Male
Female
Primary Insured DOB
*
MM slash DD slash YYYY
Height
*
Weight
*
Primary Insured Marital Status
*
Married
Single
Widowed
Divorced
Seperated
Other
Primary Insured Education Level
*
No High School
High School Diploma
Some College, No Degree
Associates
Vocational/Technical Degree
Bachelors
Masters
Medical/Law Degree
PhD
Primary Insured Occupation
*
Number of Dependents
*
Give your dependents ages
*
Underwriting Questions
Primary Insured's Total Annual Income
*
Do you have Life coverage through your employer?
*
Yes
No
If yes, what's the death benefit amount?
*
Do you have other existing life insurance policies?
*
Yes
No
If yes, how many and what are their death benefit amount for each?
*
Do you have use tobacco products?
*
Yes
No
If so, what types and how often?
*
Do you own a house?
*
Yes
No
What's the balance of the mortgage if applicable?
*
Do you/spouse have 401k accounts with past employers?
*
Yes
No
How many 401k's from past employers do you have that you may want to review for safer alternatives?
*
Do you have underlying health issues?
*
Your agent will follow up with you to get more details on this.
Yes
No
Do you currently take any prescription medications?
*
Your agent will follow up with you to get more details on this.
Yes
No
Spouse Full Name
*
Spouse Gender
*
Male
Female
Spouse DOB
*
MM slash DD slash YYYY
Final Comments
Anything else we should know or be aware of (Please do not give any medical information here)
State law requires that the customer be informed that credit information will be used during the quote/application process and that the customer be provided with a copy of the current statement. This information may also be used to provide you with a quote for other insurance products we offer. By submitting this form I certify that I have reviewed the application information contained herein. I verify that the information is true, correct and complete.
*
I agree
State law requires that the customer be informed that credit information will be used during the quote/application process and that the customer be provided with a copy of the current statement. This information may also be used to provide you with a quote for other insurance products we offer.
By submitting this form I certify that I have reviewed the application information contained herein. I verify that the information is true, correct and complete.
CAPTCHA