Get a Quote for Life Insurance We Shop All the Top Companies Next Previous Reasons to buy Life Insurance Leave a Legacy to your Loved ones Income Replacement for Family Protect House Mortgage Life Insurance is Tax Free Benefit Advantage of the Tax Free Distribution Questions to Ask About Life Insurance How Much Do I Need Reasons for Buying Life Insurance Type of Life Insurance you Need How Much is it Going to Cost How Long Do I need it to Last Get in Touch With A-1 Insurance Group, Inc. Name* First Last Phone Number*Email* Address Apt number/unit City State Zip Code County* Height*4ft5ft6ft7ft8ft9ft10ftInches123456789101112Weight Date of Birth* MM slash DD slash YYYY Use Tobacco* Yes No Health conditionsDo you take a medication?YesNoMedication Name* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 1* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 2* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 3* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 4* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 5* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 6* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 7* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 8* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 9* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 10* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 11* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 12* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 13* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 14* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 15* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 16* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 17* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 18* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 19* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 20* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 21* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 22* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 23* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 24* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 25* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 26* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 27* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 28* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 29* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 30* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 31* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 32* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 33* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 34* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 35* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 36* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 37* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 38* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 39* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 40* Quantity* Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount* Life InsuranceDo you have existing coverage?YesNoFace amount of Life Insurance (how much do you need?) How long do you need the life insurance for?*10 years15 years20 years25 years30 yearsLifetimePaid-up policyQuestions/Comments