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Type of insurance to be quoted:
$Amount of coverage:
Maximum premium:
Payment Schedule:
Insurance companies preferred, if any:
Amount & type of current life insurance:
Your e-mail address:
Repeat e-mail address:
First name:
Last name:
Address – Street:
City:
State:
Zip:
Cell Phone:
Work/Day Phone:
Home Phone:
Date of Birth
Weight-lbs
Height:
Ever used tobacco?
Type:
#yrs:
Date last used:
Ave. quantity/day:
Treated for drug or alcohol abuse in the last 5 years?
Convicted of DUI or DWI in the last 5 years?
High blood pressure (hypertension)?
Systolic-top level:
Diastolic-bottom level:
High cholesterol? Yes No Level and ratio:
All medications prescribed in the last 2 years – prescribed dosage – prescribed frequency:
Last 10 years list all – medical conditions — treatment — approximate dates:
Last 10 years list all – mental conditions — treatment — approximate dates:
If a parent or sibling died before age 60 from sickness, state who, and cause:
Dangerous sports/hobbies (include private pilot) — approx. date of last activity:
Describe any recent or planned future travel outside North America:
Have you ever been declined for life insurance? If so, give reason:
Describe your occupation — any other comments:
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