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:
*Sex: Male    Female
*Date of birth: / / (Month/Day/Year)
*Height: Feet  Inches
*Weight: Pounds
Amount?
Type of life insurance?
   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
    
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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