Life Quote

Full Name

Relationship to Primary Insured

Birth Date

Height

Weight

Social Security #

Welcome...please fill out the following form to the best of your knowledge.

Primary Proposed Insured

Name
Street Address
Address (cont.)
City
State
Zip/Postal Code
Work Phone
Home Phone
Fax
Email
Driver's License #
Social Security #

Gender
Date of Birth
Marital Status
Height
Weight
Occupation
Duties
Net Annual Income
Employer Name

Other Proposed Insureds

HEALTH STATEMENTS

1. Name, Address, Phone Number of any Proposed Insured's medical facility or physician:

2. Has any Proposed Insured ever had, sought medical advice or been treated for, or been diagnosed as having:	YES	NO
a. high blood pressure, heart attack, murmur, chest pain, or any disorder of the heart or vascular system?
b. seizures, stroke, Alzheimer's, or any other disorder of the brain or nervous system?
c. diabetes, hepatitis, or any other disorder of the endocrine or gastrointestinal system?
d. liver or kidney disorder, protein or blood in the urine, or any other disorder of the urinary or reproductive system?
e. cancer, tumor, mass, or any malignant or benign growth?
f. asthma, emphysema, tuberculosis, pneumonia, sleep apnea or any other disease or disorder of the lungs or respiratory system; arthritis or any connective tissue or musculoskeletal disorder?
g. depression, schizophrenia, or any other emotional, mental or psychiatric disorder?
h. anemia, hemophilia, high cholesterol or glucose, or any other disorder of the flood?

3. Has any Proposed Insured ever:	YES	NO
a. been diagnosed by a medical professional or received treatment for lymph gland disorder, AIDS or AIDS related condition?
b. Tested positive for HIV
c. been advised to reduce or stop drinking alcohol by a medical professional or received counseling or treatment for alcohol use or abuse?
d. attempted suicide or made suicidal gesture?
e. had any surgical operation performed or recommended?

4. Is any proposed insured currently taking or within the past year has any proposed taken any treatments or medications?

5. During the past 5 years, has any Proposed Insured:
a. seen a medical professional or been admitted to, evaluated, or treated in an urgent care center, emergency room, hospital or other treatment facility?
b. had or been advised to have urine or blood tests (excluding HIV test), x-rays, scans, EKGs, or other tests not listed?

6. Within the past 8 years, has any Proposed Insured used or received counseling or treatment of the use of any drug, including but not limited to: marijuana, cocaine, amphetamines, barbiturates, narcotics, opiates, (such as heroin), hallucinogens (such as LSD, PCP); or used to excess or received counseling or treatment for the use of any prescription medication?

7. Has any proposed insured lost more than 10 lbs in the last year?
8. Does any Proposed Insured drink alcoholic beverages?

List and explain any "yes" answers to questions 2 through 7 above

All above information is requested to complete a life insurance proposal. Once submitted, you will receive a variety of life insurance proposals. We believe in giving you choices that fit your needs and budget.