| Name
* |
| Address
* |
City
*
State*
Zip
* |
Home Phone
*
Business Phone
Cell Phone:
|
| Fax Number
|
| E-mail Address
* |
| Best place to contact you:
Business
Home |
| Are you a citizen of the United States
Yes
No |
| Gender:
Male
Female
|
|
Age:
|
| Height
ft.
in. Weight
lbs. |
|
| How much life insurance would you
like us to quote?
|
|
|
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
/
MM/YYYY
I smoke.
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 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 ten 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 your grandparents,
parents or sibling have heart disease or cancer, prior to age 60?
Yes
No
If yes, please explain:
|
|
Any other Questions or Comments?
|
|
|