South Haven Insurance Services_01-0090-00

Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number

Email

example@example.com

Best way to contact:

Individuals to Quote for Life Insurance:

Specific Life Insurance Information Needed Per Person (Most experts recommend you have 7-10 Times your income for life insurance.):

How much life insurance do you need?

How did you come up with that amount?

What Type of Insurance: (Whole, Universal, Term, Unsure)

If term insurance: How many years do you need it? (5, 10, 15, 20, 25, 30 yrs)

Person 1

Person 2

Person 3

Person 4

Have you ever had or been treated for any of the following conditions? (Please check any that apply):

Blood Pressure

Cancer

Cholesterol

Heart Problem

Depression, Anxiety

Diabetes

Alcohol or Substance Abuse

Asthma

None

Other significant issues

Person 1

Person 2

Person 3

Person 4

Specific Life Insurance Information Needed Per Person:

Do you currently have life insurance? (yes, no)

If yes, how much? ($ amount)

Do you intend to replace this insurance? (yes, no)

Before they turned 70, did any of your parents or siblings have incidents of or die from heart disease, cancer, stroke, or diabetes? (yes, no) If yes, please select option in question below.

Person 1

Person 2

Person 3

Person 4

Specific Life Insurance Information Needed Per Person:

How many tickets have you received for moving violations in the last 3 years?

How many tickets have you received for moving violations in the last 5 years?

Have you had any DUI citations? If yes, when?

Have you smoked cigarettes in the last 5 years? (yes or no & if yes

Have you used any other forms of tobacco or nicotine in the last 5 years?

Person 1

Person 2

Person 3

Person 4

Specific Life Insurance Information Needed Per Person:

In the past 2 years, did you live or travel outside the U.S. or Canada?

In the next 2 years, do you have any plans to live or travel outside the U.S. or Canada?

Have you ever flown in an aircraft in any capacity other than a passenger?

Have you done any SCUBA diving in the last 3 years?

Do you engage in any hazardous sports or activities?

Person 1

Person 2

Person 3

Person 4

Verification Code - Enter the message as it's shown: *

Life Insurance Quote