The easiest way to give you the most accurate information  possible upfront is to contact a Moors & Cabot Licensed Agent. By providing us with thorough details on your health, family health history, and other possible risk factors, our Licensed Agents will be able to impartially shop and match you with the company we represent that offers the lowest price for you.

The 15 minutes you spend with us may save you hundreds of dollars and spare you wasted weeks pursuing a policy you can't qualify for.

Getting Started

Step 1 of 5

This information is requested only to assist us in providing you accurate information. Filling out this on-line form does not constitute an application for insurance.

In order to match you with the right company, service and coverage for you, we need to know a little about you. 

These questions take only a few minutes, and your information will be used solely for the purpose of finding you the best policy at the lowest price available from the insurance companies we represent in your state. 

At any point in the process, feel free to call toll-free, 1-800-666-6646, Monday through Friday. I'll make the entire process quick and easy (no typing required!).

1. Tell us a little about you.
Different insurance companies charge different prices for the same coverage based on personal factors such as your age, health, and lifestyle - often that difference is hundreds of dollars per year!

2. Submit the form.
I will research our pick of America's most highly rated insurance companies and call you within 24 hours to discuss your options
Title *
First Name *
Last Name *
In which state do you live? *
Not available in SD or outside the US.
Date of birth    mm   dd   yyyy 
Gender  
Height    ft.   in. 
Weight    lbs. 
Have you ever had or been treated for any of the following conditions?  

No
Blood Pressure
Cancer
Cholesterol
Heart Problem
Depression, Anxiety
Diabetes
Alcohol or Substance Abuse
Asthma
Other significant issues
Do you currently have a life insurance policy?   Yes    No   
What is the coverage on your existing life insurance policy?  
Numerals only. No punctuation. (e.g. 100000)
Are you planning to replace this coverage?   Yes    No   
Experts typically recommend that you purchase coverage of 7-10 times the amount of annual income you need to replace.
Amount of coverage you wish to obtain:  
Alternate amount:  
Desired duration of policy (years):  
To offer the right rate, insurance companies consider your family's health history an important factor in determining your final price.
If you are adopted, check here and click Next to continue.  
Before they turned 70 , did any of your parents or siblings have incidents of or die from heart disease, cancer, stroke, or diabetes?   No
Yes, the following occurred:
Father:   Cancer
Heart
Diabetes
Stroke
Mother:   Cancer
Heart
Diabetes
Stroke
Siblings:   Cancer
Heart
Diabetes
Stroke
Your lifestyle may include risks that an insurance company must take into account.
How many tickets have you received for moving violations in the last 3 years?  
How many tickets have you received for moving violations in the last 5 years?  
Have you had any DUI citations?  
Have you smoked cigarettes in the last 5 years?  
Have you used any other forms of tobacco or nicotine in the last 5 years?  
In the past 2 years, did you live or travel outside the U.S. or Canada?   Yes    No   
In the next 2 years, do you have any plans to live or travel outside the U.S. or Canada?   Yes    No   
Have you ever flown in an aircraft in any capacity other than a passenger?   Yes    No   
Have you done any SCUBA diving in the last 3 years ?   Yes    No   
Do you engage in any hazardous sports or activities?  
Street  
City  
State  
Zip  
Office Phone #  
 -   -   ext. 
Home Phone #  
 -   - 
E-Mail address: *

I am ready to submit my information.