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Questionnaire

“*” indicates required fields

Name*Email*Phone*Age?*Marital Status?Total death benefit from policies*

Do you (or does our business) own life insurance?*

YesNo

Do you (or your business) own key man insurance?*

YesNo

Term Life AND if YES check all that apply

Convertable Term20 year annual renewable10 year annual renewable5 year annual renewable

Universal Life AND if YES check all that apply*

Indexed UniversalGuaranteed UniversalVariable Universal

Whole Life AND if YES check all that apply*

Mutual Whole LifeStock Whole LifeMaximized Death BenefitMaximized Cash Value Growth

Additional life insurance required?*

YesNo

Describe life insurance goals and concernsHeirs or Other Beneficiaries?*

Identify heirs such as siblings, children, grandchildren OR other beneficiaries...include name, approximate age, and relationship.

Do any of the following circumstances apply to your estate?*

You're unmarried and in a non-traditional relationship.You're current marriage is not your first.You have children from prior marriages.You or a family member is receiving or may need full time skilled nursing care.You have aging parents who need planning for long term medical care.You have children or other dependents with special needs.You have children who struggle with drug and alcohol abuse.You and/or your spouse own a businessYou and/or your spouse own real estate investments.You owe unpaid creditors.Other

Total estimated gross value of assets?*

Identify real estate, financial accounts, personal property vehicles, collectibles, etc.

Total approximate debt owned to creditors?*

Identify all parties who may be considered lenders with unpaid balances such as banks, credit card companies, finance companies and all other third parties with outstanding loans subject to be repaid.

Identify desired estate appointees and successors?*

Include name, relationship, approximate age, and state of residence (key roles are trustee, personal representative/executor, legal guardian, power of attorney, and healthcare surrogate).

Additional information?

May include your personal goals and/or concerns OR description of ANY other matter pertaining to your unique circumstances.

By pressing the Submit button, you agree to use InsuranceandEstates’ privacy policy and terms. InsuranceandEstates may contact you at the number you entered on this webpage using our automatic dialing system to market our life insurance products. Alternatively, you can contact us at 877-787-7558. I read the disclaimer above.* Yes

*Submission of information to insuranceandestates.com, Steven Gibbs or Insurance & Estate Strategies, LLC does not establish an attorney-client relationship betwe with the user. We are acting as attorneys or agents and no representation can be presumed unless and until the terms of the agreement are confirmed in writing.

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Privacy & TOU | Accessibility | Licenses

Licensed name varies by state: Insurance and Estate Strategies LLC; in California, Steven J. Gibbs, CA License #0K10610; in New York, Steven J. Gibbs, NY License #1495640. © 2026 Insurance and Estate Strategies LLC. All rights reserved.

Disclaimer (click to read)

The content on this website is for informational purposes only. It is not intended to be a substitute for professional financial, tax, or legal advice. All information is provided in good faith, however we make no representation or warranty of any kind, express or implied, regarding the accuracy, adequacy, validity, reliability, availability or completeness of any information on this site. Under no circumstance shall we have any liability to you for any loss or damage of any kind incurred as a result of the use of the site or reliance on any information provided on the site. Your use of the site and your reliance on any information on the site is solely at your own risk.

Life insurance policies are not investments and, accordingly, should not be purchased as an investment. In addition, by using this website, I confirm that I understand and agree to the applicable Privacy Policy and Terms of Service. I understand that by calling the phone number above I will reach a licensed sales agent. 2325 E Camelback Road, Suite 400, Phoenix, AZ 85016. InsuranceandEstates.com is a free information source designed to help find insurance coverage. We compile our data from multiple sources, which includes the government, non-profit and private sources. The rates and information displayed are for informational purposes only and should not be construed as advice, consult, or recommendation. For specific plan details and further information, contact carriers directly.

Steven Gibbs is domiciled in Arizona. See the jurisdictions in which Steven Gibbs and our other agents are licensed, admitted or otherwise authorized to market insurance products and/or legal services to consumers. This website is provided by Steven Gibbs and Insurance and Estate Strategies LLC, an Arizona limited liability Company, in order to educate and inform the general public of the services we offer only. Due to Steven Gibbs active license as an attorney in Florida, this website may be interpreted to constitute attorney advertising. Submission of information to insuranceandestates.com or use of this website, does not constitute an attorney-client relationship with Steven Gibbs unless and until the terms of an attorney-client agreement are confirmed in writing.

By completing a questionnaire or requesting information from insuranceandestates.com, you consent and expect to be contacted by a licensed insurance agent via phone, email, text or direct mail. Insuranceandestates.com will not sell your information to a third party. Any health or personal information shared is protected by applicable HIPAA privacy laws and regulations. Insuranceandestates.com affiliated agents are independent and appointed in multiple states. Invitations for application for life insurance on insuranceandestates.com are made through its designated agent, Steven Gibbs, only where he is respectively licensed and appointed.

See our Licenses page. Additional licenses of Steven Gibbs are available upon request. No portion of insuranceandestates.com may be copied, published, faxed, mailed or distributed in any manner for any purpose without prior written authorization of the owner. If an InsuranceandEstates visitor requests a quote, Insuranceandestates.com may enlist the help of other independent agents to help its customers find the best values. Life insurance policies described, quoted, shown and illustrated throughout this website are not available in all states. Rates and time taken to qualify and purchase a life insurance policy vary by product and underwriting requirements.

Insurance and Estates is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to amazon.com.

The Infinite Banking Concept® is a registered trademark of Infinite Banking Concepts, LLC. Insurance and Estates is independent of and is not sponsored by, endorsed by, or affiliated with Infinite Banking Concepts, LLC.

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