Let's Protect Your Legacy

Let's Protect Your Legacy

Insurance Quote Form
Tell Us About You

All information is kept in strict confidence.
Who is this insurance quote for*
All questions on this form pertain to the person to be insured.
Full Name of person *

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How many years at this address? (If less than 1 year use 0)*
Phone Number*
E-mail*
example@example.com
Birth Date*

MonthDayYear
Age*
Height*
example: 6'1''
Weight*
example: 110lbs
Gender*
What type of insurance are you looking for?*
Who will be responsible for the monthly premium?*
What monthly premium fits comfortably into your budget?*
example: $200 , $100
How much life insurance coverage are you interested in?
Is your driver's license suspended or revoked?*
In the past 5 years have you had a DUI or DWI?*
Do you have a criminal history within 10 years? (Arrested, convicted, open case)*
Health Questions

Please describe any health issues below.
Are you currently disabled, hospitalized or in a nursing facility?*
Have you ever had any heart, lung, circulation, kidney, or major health issues in the last 5 years?*
Have you had surgery (not including cosmetic) in the past 3 years?*
Have you ever been diagnosed with cancer or have you had a stroke?*
Have you ever been diagnosed with diabetes?*
Do you smoke cigarettes or use any form of tobacco or nicotine?*
Do you use any drugs?*
In the past 10 years, have you had a blood pressure reading over 135/85?*
Do you take any medications?*
Are you NOT taking any medications prescribed by a doctor? If this is the case, please list those meds. If not applicable, type N/A*
Please list any medications prescribed by a physician. (Note, for an accurate quote, we need to know ALL Medications prescribed by a physician)
Existing Life Insurance?
Do you have any existing life insurance now?
If so, who is this existing policy with?
Are you planning on cancelling any existing life insurance?

YesNo
Do you have group life insurance through work?

YesNo
Please add any additional comments or questions:
Should be Empty:

Let's Protect Your Legacy

All questions on this form pertain to the person to be insured.

Health Questions