Please fill form out
completely
* = Required
*Name:
*Address:
*City:
*State:
*Zip:
*Current Career:
*Type of Business:
*Current Policy Expires:
/
/
(Month/Day/Year)
(Leave blank if no current policy.)
*Daytime Phone:
*Evening Phone:
Fax Number:
*Email:
Best time to Contact:
Evenings
Daytime
Weekends
*Sex:
Male
Female
*Date of birth:
/
/
(Month/Day/Year)
*Height:
Feet
Inches
*Weight:
Pounds
Amount?
$500,000
$100,000
$200,000
$250,000
$500,000
$750,000
$1,000,000
$1,500,000
$2,000,000
$3,000,000
$5,000,000
$7,500,000
$10,000,000
Type of life insurance?
1 Year ART (Annually Renewable Term)
5 Year Guaranteed Level Premium Term
10 Year Guaranteed Level Premium Term
15 Year Guaranteed Level Premium Term
20 Year Guaranteed Level Premium Term
30 Year Guaranteed Level Premium Term
Universal Life
Whole Life
2nd-to-die (Survivorship Insurance)
Other
Description of other type of coverage you are looking for:
The coverage to be quoted will likely be:
New coverage (I have none now)
Additional coverage
Replacement of existing coverage
Tobacco Usage
I have never smoked.
I used to smoke, but I quit in
Jan
Feb
Mar
April
May
June
July
Aug
Sept
Oct
Nov
Dec
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
Before 1990
I smoke no more than one pack of cigarettes per day.
I smoke more than one pack of cigarettes per day.
I smoke cigars.
I smoke a pipe.
I chew tobacco.
I am on "the Patch."
Do you take any prescription medication?
Yes
No
If yes please explain.
Do you have any health problems?
Yes
No.
If yes please explain.
Are you a private pilot?
Yes
No.
If yes, please explain type of rating, type of aircraft,
total number of hours experience, and hours flown per year:
Do you engage in scuba diving, sky diving, rock climbing, motorized racing, or other hazardous avocation or occupation?
Yes
No
If yes, please explain in detail:
Have you been convicted of drunk driving, or had your drivers
license suspended or revoked in the past five years?
Yes
No
If yes, please explain in detail:
Have you been convicted of three or more moving violations in the
past three years?
Yes
No
Have you ever been convicted of a felony?
Yes
No
If yes, please explain dates, charges, and details:
In the past 10 years, I have been advised regarding,
or been treated for:
Hypertension
Heart Disease
Cancer
Diabetes
Stroke
Alcohol or Drugs
HIV
Other
If you checked any of the above, please explain:
Did any of your grandparents, parents or siblings have heart
disease or cancer, prior to age 65?
Yes
No.
If yes, please explain:
Additional Comments:
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