LIFE INSURANCE QUOTE QUESTIONNAIRE

PERSONAL INFORMATION & MEDICAL HISTORY (please fill out the following in order to be provided with the best possible quote)

Name:

Address:

Home Phone:

Work Phone:

Cell Phone:

Email Address:

Date of Birth (mm/dd/yy):

Gender: Male Female

Height:

Weight:

Occupation:

Annual Income:

Have you ever been treated for one of the following conditions?

None Asthma Blood Pressure Cancer Cardiac Condition Cholesterol Depression or Anxiety Diabetes Stroke Alcohol or Substance Abuse Other Significant Issues

If Other, Please Explain:

Before the Age of 65, Did A Parent Or Sibling Die From Heart Disease, Cancer, Stroke or Diabetes? Yes No

POLICY INFORMATION (please fill out the following regarding any current coverage and desired coverages)

Do You Have Any Existing Life Insurance? Yes No

Are You Planning on Replacing Existing Life Insurance? Yes No

How Much Coverage Do You Currently Have In Place?

Amount of Coverage Requested?

Desired Duration Of Policy?

ADDITIONAL INFORMATION (The following information is necessary to provide you with an accurate quote)

How Many Moving Violations Have You Received In The Past 3 Years?

How Many Moving Violations Have You Received In The Past 5 Years?

Have You Been Convicted of a DWI or DUI in the Last 5 Years? Yes No

Have You Ever Been Convicted of a Felony? Yes No

If Yes, Please Explain:

Do You Currently Or Have You Ever Used Any Tobacco Or Nicotine Products? Yes No

If Yes, Please List Type and Duration of Use

Over the Past Two Years Did You Live or Travel Outside of the U.S. or Canada? Yes No

Over the Next Two Years Do You Plan To Live or Travel Outside the U.S. and Canada? Yes No

Have You Ever Flown In An Aircraft In Any Capacity Other Than A Passenger? Yes No

Do You Engage In Any Hazardous Activities? Yes No

If Yes, Please Explain: