Please fill out completely!

Name:
 
Address:
 
City:
 
State:
  
Zip Code:

Daytime Phone:
 
Evening Phone:
 
Fax Number:
 
E-mail Address:
 

Best time to contact you:
Daytime Evening

Best place to contact you:
Work Home

Sex:
Male Female

Date of birth:
Month/Day/Year / /

Your Height:
Feet Inches
Your Weight:
pounds

How much life insurance would you like us to quote?
Select One $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

What type of life insurance are you looking for?
Select One 20 Year Guaranteed Level Premium Term 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 25 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 Before 1990 1996 1995 1994 1993 1992 1991 Before 1990
I smoke cigarettes.
I smoke cigars, pipe, or chew tobacco.
I am on "the Patch" or other smoke ending plan.

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
AIDS Other

If you checked any of the above, please explain:

My latest cholesterol reading is:

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?