Thank you for your interest in a customized quote for life insurance. Based on the information you provide, we will search for the best and most economical options available, and will contact you within 24 hours to discuss these options with you.

David Ross & Associates is licensed in the states of Georgia and Tennessee, and this form is intended only for current residents of those states. Your information, including your email address, will be kept strictly confidential and will not be shared, except under the following condition: If you live outside Georgia or Tennessee, we may elect to forward your information to one, and one only, agent licensed in your resident state who will then contact you regarding your life insurance needs.

Your Name
Your Email Address
Your Age
Your Gender
Your Height
Your Weight
What types of life insurance are you looking for?	Term Life Whole Life Universal Life A combination of types
Primary purpose for life insurance	Income replacement Mortgage protection Final expenses More than one purpose
What amout of coverage?
Would new coverage be for yourself only, or also for spouse and/or children?	Self only Self and spouse Self, spouse and child(ren) Self and child(ren)
When do you need new coverage?
Some companies require a physical exam (at company's expense); some don't. Are you willing to have an exam?	Yes No
Have you used tobacco in the past 12 months?	Yes No
Are you currently taking any prescription medications other than temporary antibiotics?	Yes No
Have you been diagnosed or treated for heart disease or cancer in the past five years?	Yes No
Are you or your spouse currently pregnant?	Yes No
Your Mailing Address
Your Phone Number
When is the best time to speak with you by phone?
Additional comments or information