Life and Health Quote Sheet

Applicant Information

Name

Address

City

State

ZIP

E-Mail

Phone Number

Best time to call

Occupation

Please list your: Height Weight

How would you describe your personal health? Excellent Good Fair Poor

Have you used any tobacco products in the past 10 years? Yes No

If yes: cigarette cigar pipe smokeless

when did you quit? Mo /Yr

Have not quit

Number or years as a smoker

Number of packs a day

In the past 10 years, have you been treated for or had any of the following? Cancer AIDS Surgery Diabetes
High blood pressure Circulatory disorder Heart disease

Do you participate in any high risk activities? Yes No

If Yes, please explain.

Are you taking any medications? Yes No

If Yes, type and dosage.

Do you currently have insurance? Yes No

If Yes, with whom?

What type? Term Universal Whole Varible Major medical PPO HMO N/A

What amount/deductible?

Do you feel that is ample for your needs? No Yes

What is your premium (monthly or annually?)

Additional Applicants' Information

Additional Applicant 2

Name

Date of birth: Mo Day Year

Current Health condition Excellent Good Fair Poor N/A

What amount/deductible?

Relationship?

Additional Applicant 4

Name

Date of birth: Mo Day Year

Current Health condition Excellent Good Fair Poor N/A

What amount/deductible?

Relationship?

Additional questions or comments.