Life Insurance Quote Form
Name:
Address:
E-mail Address:
Phone:
I am requesting information about
Life Insurance
Term & Permanent
Mortgage and Family Protection
Health Insurance
Major Medical and Medicare
Insurance Amount:
>
100,000
200,000
250,000
300,000
400,000
500,000
600,000
700,000
750,000
800,000
900,000
1,000,000
2,000,000
3,000,000
Duration:
>
10 years
15 years
20 years
30 years
To age 95
Date of Birth:
Gender:
>
Male
Female
Tobacco Use (past 3 yrs):
>
No
Smoker
Smokeless Tobacco
Health Class:
>
Preferred Plus
Preferred
Standard
Sub-Standard
See Below to Determine
Health Class
Determine Your Health Class
Preferred Plus:
Excellent health. Good cholesterol ratios. No medications and no premature family diagnosis of heart disease or cancer.
Preferred:
Good health. Normal weight. No medications and no premature family death of heart disease or cancer.
Standard:
Fair health. Some major health conditions allowed.
Sub-Standard
: Poor health or obese. If insurable, your premium could be several times more than standard rate.