Quote Requests

Thank you for visiting TPM Request for Quote page. Send us your quote request today and let the knowledgeable, experienced members of the TPM team work for you!


To request an individual quote, click here. Please be sure to include the following when requesting a quote:

Agent Information
Agent Name:
Phone number:
E-mail address:



Client Information
Name:
City/State/County/Zip:
Gender:
Age/DOB:
Tobacco Use?:
Height and Weight
Spouse Name:
Spouse Age/DOB:
Number of Children:
Age & Gender of Children:
Health issues:
Medications currently taking:



Coverage Information

Individual Health
Deductible:
Coinsurance:
Rx option:
Dental option:
HSA:

Individual Disability
Occupation:
Annual Salary:
Benefit Period:
Elimination Period:
Other DI coverage in force ?

Individual Life
Type of life ins:
*If Term, how long?:
Face Value:
Group Medical

Nature of Business
Location:
Out of area employees:
# employees:
**INCLUDE COPY OF CENSUS

Long Term Care

Benefit Period:
Elimination Period:
Daily Benefit amt
% Level of Home Health Care