Life Quick Quote

The essentials to get indications and start a full application. Complete the essentials below to receive coverage indications. For formal underwriting we will follow up with the full application.

Indications are non-binding until a policy is issued.

Works on any phone, tablet, or computer — no app needed. Type N/A where a field does not apply. Fields marked * are required.

Proposed Insured

Date Needed / Due

Desired Effective Date

How Did You Hear About Us?

Referred By (name)

Proposed Insured — Full Legal Name *

Date of Birth *

Gender

Street Address *

City *

State of Residence *

ZIP *

Phone Number *

Best Time to Call

Can We Text You?

Email *

SSN (optional)

Occupation / Profession

Approx. Annual Income $

Policy Owner

Is the policy owner the same as the proposed insured? *

Policy Owner Information

Complete this only if the owner is a different person or entity than the proposed insured.

Owner Full Legal Name

Relationship to Proposed Insured

Owner Date of Birth

Owner Phone

Owner Email

Owner Street Address

Owner City

Owner State

Owner ZIP

Owner Tax ID / SSN (optional)

Coverage Requested check the product(s) of interest

Term Life Whole Life Universal Life / IUL Final Expense Not sure — recommend for me

Face Amount Requested $

Term Length (if term)

Payment Mode

Total Current Life Insurance In Force $

Do you have a set budget you do not want to exceed?

Maximum Budget $

Budget Basis

Replace existing coverage?

Purpose of Coverage (income replacement, mortgage, final expense, estate, business, etc.)

Advanced / High-Net-Worth Tax Planning optional

High-net-worth? Permanent life can minimize income & estate taxes — tax-deferred cash value, tax-free policy loans, and an ILIT-owned death benefit outside the taxable estate. Ask about premium-financed and defined benefit / cash-balance funding. JAIG coordinates with your CPA / attorney and does not provide tax or legal advice. Check any of interest:

Estate-tax liquidity / wealth transfer Premium-financed policy Defined benefit / cash-balance Tax-deferred cash value / ILIT Tax-free income via policy loans Not sure — recommend a strategy

Health Snapshot drives the rate class on your indication

Height

Weight (lbs)

Tobacco / Nicotine Use

Expected Rate Class

Ever been treated for heart disease, cancer, stroke, or diabetes?

Any surgery, hospitalization, or ongoing treatment in the last 2 years?

Currently disabled or applying for disability benefits?

DUI / DWI or license suspension in the last 5 years?

Hazardous activities or aviation (pilot, racing, scuba, etc.)?

Ever been declined, postponed, or rated for life insurance?

Current medications & details for any "Yes" above (condition, date, treatment, status)

Beneficiary

Primary Beneficiary

Full Name

Relationship

Date of Birth

Distribution %

Contingent Beneficiary

Full Name

Relationship

Date of Birth

Distribution %

Authorization & Return

Authorization & Broker of Record / Exclusive Representation Acknowledgment *
I authorize J. Archer Insurance Group to obtain the information needed to market my coverage and to act as my exclusive broker for this submission. I certify the above is true and complete to the best of my knowledge. Indications are non-binding until a policy is issued.

Applicant Signature (type full name) *

Date *

Print Name

Tap Submit to send your answers to our team, or Save / Print as PDF to keep a copy and email it to service@archerinsgroup.com. Questions? Call 281-501-8331.

What Happens Next

The moment we receive your quick quote, you'll be immediately assigned to your own dedicated insurance advisor and legacy planning team — a group of experts working specifically for you and your family.

Your team brings deep, hands-on experience across life and health insurance, asset protection, and legacy and tax-advantaged growth planning, and will guide you through every step from your first indication to an issued policy.