Life Insurance Quote

For your personalized life insurance quote, please use this form. Alternatively, feel free to call us toll-free (866-633-1818), or send an email ( Thank you!


Term Life Insurance
Permanent Life Insurance
I'm not sure


$1,000,000 to $2,000,000
$2,000,000 to $3,000,000
$3,000,000 to $4,000,000
$4,000,000 to $5,000,000
Over $5,000,000


Estate planning
Income replacement
Mortgage protection
Divorce settlement

Secure a business loan
Fund a buy-sell agreement
Key Man insurance

Medical History

As a starting point only, please provide a rough idea of your circumstances. Your information is held in strict confidence (Privacy). We do not submit formal applications without express permission. And please don't worry about being declined, even with a serious illness. Aggressive underwriting is our specialty.

History of substance abuse (alcohol, prescription drugs, steroids, etc)
Psychology (anxiety, depression, bipolar, etc)
Neurology (seizures, paralysis, etc)
Circulation (heart disease, arrhythmia, stroke, etc)
Respiration (sleep apnea, COPD, etc)
Gastroenterology (hepatitis, colitis, etc)
Endocrinology (diabetes, thyroid disorder, etc)
Immunology (scleroderma, lupus, arthritis, etc)

Lifestyle and Occupation

Rock Climbing
SCUBA Diving
Extreme Sports
Foreign Travel


Have you been rated or declined for life insurance? Why? How much coverage do you have now? Anything else you'd like us to know as we prepare your life insurance quote?

Please do not send sensitive financial information (such as socical security number) through this life insurance quote form. Such information is completely unnecessary for a life insurance quote. Thank you.


Name: (First name is okay)
State: (See where we are licensed)
Phone: (Why required?)

All contact fields required. Your information is held in strict confidence (our privacy policy).

NOTES: Prequalification is offered with no obligation, whatsoever. A prequalified life insurance quote is typically honored by the underwriter for 30 days. In our experience, consumers who spend at least $50 monthly on their life insurance premium will derive the greatest cost-saving benefit from their prequalified life insurance quote.

Steven Kobrin, LUTCF, is life insurance licensed in DC and 48 states. Residents of Hawaii and Alaska should NOT request a life insurance quote. Use of this web site indicates understanding of these statements.

Steven Kobrin, LUTCF
6-05 Saddle River Rd #103
Fair Lawn, NJ 07410
(866) 633-1818 Phone
(201) 796-8244 Fax

Copyright ©
by Steven Kobrin, LUTCF. All rights reserved.