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NAME |
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ADDRESS |
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CITY |
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STATE |
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ZIP
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DAYTIME PHONE |
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EVENING PHONE |
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FAX NUMBER |
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EMAIL ADDRESS |
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BEST TIME TO CONTACT YOU |
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SEX |
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MALE
FEMALE |
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DAY OF BIRTH
MM/DD/YYYY |
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HEIGHT |
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WEIGHT |
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HOW MUCH LIFE
INSURANCE WOULD YOU LIKE US TO QUOTE |
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WHAT TYPE OF
LIFE INSURANCE ARE YOU LOOKING FOR |
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DESCRIPTION OF
OTHER TYPE OF COVERAGE YOU ARE LOOKING FOR |
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THE COVERAGE TO
BE QUOTED WILL LIKELY BE |
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NEW COVERAGE (I
HAVE NONE NOW) |
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ADDITIONAL
COVERAGE |
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REPLACEMENT OF
EXISTING COVERAGE |
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TOBACCO USAGE |
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I HAVE NEVER
SMOKED |
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I USED TO SMOKE
BUT I QUIT IN |
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I SMOKE NO MORE
THAN ONE PACK OF CIGARETTES PER DAY |
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I SMOKE MORE
THAN ONE PACK OF CIGARETTES PER DAY |
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I SMOKE CIGARS |
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I SMOKE A PIPE |
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I CHEW TOBACCO |
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I'M ON THE PATCH |
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DO YOU TAKE ANY
PRESCRIPTION MEDICATION |
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YES
NO |
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IF YES, PLEASE
EXPLAIN |
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DO YOU HAVE ANY
HEALTH PROBLEMS |
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YES
NO |
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IF YES PLEASE
EXPLAIN |
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ARE A PRIVATE
PILOT |
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YES
NO |
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IF YES PLEASE
EXPLAIN TYPE OF RATING, TYPE OF AIRCRAFT, TOTAL NUMBER OF
HOURS EXPERIENCE AND NUMBER OF HOURS FLOWN PER YEAR |
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DO YOU ENGAGE IN
SCUBA DIVING, SKY DIVING, ROCK CLIMBING, MOTORIZED RACING,
OR OTHER HAZARDOUS AVOCATION OR OCCUPATION |
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YES
NO
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IF YES PLEASE
EXPLAIN DETAILS: |
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HAVE YOU BEEN
CONVICTED OF DRUNK DRIVING OR HAD YOUR DRIVING LICENSE
SUSPENDED OR REVOKED IN THE PAST FIVE YEARS? |
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YES
NO |
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IF YES PLEASE
EXPLAIN IN DETAIL |
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HAVE YOU BEEN OF
THREE OR MORE MOVING VIOLATIONS IN THE PAST THREE YEARS? |
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YES
NO |
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HAVE YOU EVER
BEEN CONVICTED OF A FELONY |
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YES
NO |
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IF YES PLEASE
EXPLAIN DATES, CHARGES AND DETAILS |
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IN THE PAST 10
YEARS I HAVE BEEN ADVISED REGARDING OR BEEN TREATED FOR |
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HYPERTENSION |
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HEART DISEASE |
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CANCER |
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DIABETES |
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STROKE |
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ALCOHOL OR DRUGS |
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AIDS |
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OTHER |
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IF YOU CHECKED
ANY OF THE ABOVE PLEASE EXPLAIN |
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DID AY OF YOUR
GRANDPARENTS, PARENTS OR SIBLINGS HAVE HEART DISEASE OR
CANCER PRIOR TO AGE 65 |
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YES
NO |
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IF YES PLEASE
EXPLAIN |
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OTHER QUESTIONS
AND COMMENTS |
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