Life Insurance Quote Questions
Please answer the following questions so we can get you a quote on Life Insurance. If you have any questions please call the office at 308 534 9050 or text us at 308 536 6050.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
What is your social security number?
*
What is your drivers license number?
*
What is your occupation and what is your employers name?
*
What is your approximate annual income?
*
Height
*
Weight
*
Who is your primary care physician?
*
Have you, in the past 2 years, used Tobacco or Nicotine products in any form (e.g. cigarettes, pipes, cigars, snuff, chewing tobacco or nicotine delivery devices such as gum or patch, or Marijuana)? *
Yes
No
Date of last use
-
Month
-
Day
Year
Date
Have you, in the past 5 years, been admitted or advised to be admitted to any hospital or health care facility; or undergone or been advised to have surgery, biopsies, treatment or medical test?
*
Yes
No
Please provide a breif explanation
Have you, in the past 5 years, been diagnosed by a member of the medical profession for any illness, disease, or injury?
*
Yes
No
Please provide a breif explanation
Have you, in the past 5 years, been prescribed any prescription medication by a member of the medical profession for any illness, disease, condition, or injury?
*
Yes
No
Please list medication and dose and how long they have been used.
Have you, in the past five years, been disabled, received disability income benefits, or been unable to work or perform and carry out your normal daily functions for any reason other than maternity leave or recovery from minor surgery?
*
Yes
No
Please explain
Have you ever been treated for drug or alcohol addition?
*
Yes
No
Date treatment ended
-
Month
-
Day
Year
Date
Have you ever attempted suicide?
*
Yes
No
Have you, in the past 10 years, had your driver’s license suspended, revoked, pled guilty to, or been convicted of reckless driving, or driving under the influence (DUI/DWI)?
*
Yes
No
Date of offense
-
Month
-
Day
Year
Date
Have you, in the past 10 years, pled guilty to or been convicted of a felony or misdemeanor, or are such charges pending against you, or are you currently on parole or probation?
*
Yes
No
Please explain and date
Have you had an application for life, accident, or health insurance, or reinstatement of a policy, declined, postponed, cancelled, or issued other than as applied for?
*
Yes
No
Please explain
Within the next two years, do you plan to work or reside outside the US?
*
Yes
No
Have you, in the past two years, flown as a student pilot, pilot or crewmember (or do you plan to within the next two years)?
*
Yes
No
Are you a member of the military, military reserve or National Guard (active or inactive) or do you have a written agreement to become a member at a future date?
*
Yes
No
Have you, in the past two years, or do you plan to in the next two years, take part in hang gliding, para sailing, para kiting, parachuting, skydiving, ultralight, soaring, ballooning, bungee jumping, rock or mountain climbing, organized racing by automobile, motorcycle, powerboat or snowmobile, or underwater diving?
*
Yes
No
Within the past 90 days have you been unable to perform the normal duties of your occupation for 15 or more working days because of health reasons?
*
Yes
No
Please Expalin
Do you have another person that you would like a quote on?
Yes
No
Submit
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