Life Insurance Quote
Glavinsured Agency, Inc.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Best way to contact:
Are you a current customer of Glavinsured Agency, Inc.?
Yes
No
What agent with Glavinsured Agency, Inc. are you working with?
How many people do you want the quote on?
How did you hear about us?
If this is a referral, who referred you:
From which of our office locations would you prefer to be contacted?
Please Select
Necedah, WI
Wrightstown, WI
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.):
Rows
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):
Rows
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:
Rows
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:
Rows
Father
Mother
Siblings
Person 1
Cancer
Heart
Diabetes
Stroke
Cancer
Heart
Diabetes
Stroke
Cancer
Heart
Diabetes
Stroke
Person 2
Cancer
Heart
Diabetes
Stroke
Cancer
Heart
Diabetes
Stroke
Cancer
Heart
Diabetes
Stroke
Person 3
Cancer
Heart
Diabetes
Stroke
Cancer
Heart
Diabetes
Stroke
Cancer
Heart
Diabetes
Stroke
Person 4
Cancer
Heart
Diabetes
Stroke
Cancer
Heart
Diabetes
Stroke
Cancer
Heart
Diabetes
Stroke
Specific Life Insurance Information Needed Per Person:
Rows
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:
Specific Life Insurance Information Needed Per Person:
Rows
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
yes
no
yes
no
yes
no
yes
no
yes
no
Person 2
yes
no
yes
no
yes
no
yes
no
yes
no
Person 3
yes
no
yes
no
yes
no
yes
no
yes
no
Person 4
yes
no
yes
no
yes
no
yes
no
yes
no
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