Best time to
contact you:
DaytimeEvening
Best place to contact
you:
WorkHome
Sex:
MaleFemale
Date
of birth: Month/Day/Year
/
/
How much life
insurance would you like us to quote?
What type of life
insurance are you looking for?
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 driver's 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
AIDS
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:
Any other Questions or
Comments?
