Life Insurance Quote Request
Filkins Colbert & Associates Insurance
Name:
First Name
Last Name
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
example@example.com
Date of Birth:
Life Insurance Coverage Amount:
Height:
Weight:
When have you most recently used tobacco or nicotine? (in months):
Has any sibling or parent of the proposed insured died from or been diagnosed with cancer or cardiovascular disease prior to age 65?
Yes
No
Have you ever been told you have high blood pressure or hypertension?
Yes
No
In the past 3 years, have you had more than 3 speeding tickets or other moving violations?
Yes
No
In the past 5 years, have you had any DUIs, license suspensions, or revocations?
Yes
No
Have you ever been told you have, or received treatment or medical advice for any of the following conditions? If yes, specify which.
AIDS, ARC, or HIV positive
Alcohol or drug abuse
ALS (Lou Gehrig’s Disease)
Atrial fibrillation
Barrett’s esophagus
Bipolar disorder
Cancer (other than certain skin cancers)
Crohn’s disease
Diabetes
Emphysema or COPD
Epilepsy or seizures
Gastric bypass or lap band surgery
Heart attack
Heart disease, heart failure, or heart valve replacement
Hepatitis B or active Hepatitis C
Kidney disease
Liver failure
Lupus
Melanoma
Multiple sclerosis (MS)
Parkinson’s disease
Peripheral artery or vascular disease (PAD/PVD)
Rheumatoid arthritis
Sleep apnea
Stroke or transient ischemic attack (TIA)
Ulcerative colitis (UC)
Have you used marijuana at any time in the past 5 years?
Yes
No
Have you ever had a life or health insurance application declined, postponed, modified, or issued at a higher rate due to health or lifestyle factors?
Yes
No
Please verify that you are human
*
Submit
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