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Personal Insurance Quote General Information:
First Name:
Middle Initial:
Last Name:
Date of Birth:
Phone Number:
Email:
City:
State:
Height:
Weight:
Any weight loss in the last 12 months?
How much?:
Any current or past tobacco or nicotine use?
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Yes
No
If yes, what type?
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Cigarettes
Cigars
Chewing
Snuff
Smokeless
Other
If stopped, date of last use (most recent year used)?
Employed?
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Yes
No
Occupation:
Current Annual Income:
Are you currently diagnosed with or have you been diagnosed with?
High Cholesterol
High Blood Pressure
Sleep Apnea
Diabetes
Cancer
Additional Health Comments:
Family History
Have they had?
Age if living
Age at Death
Cause of Death
Cancer
Diabetes
Heart Disease
Mom
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Yes
No
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Yes
No
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Yes
No
Dad
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Yes
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Siblings
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No
Are you taking any prescription medications?
Prescription Name
Date Started
Daily Dosage
Have you traveled outside the US or Canada in the last 3 years or do you plan to travel outside the US and Canada in the next 2 years? List locations and how long you stayed
City and Country
Year
Length of stay
Are you a pilot?
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Yes
No
Do you participate in any hazardous sports such as hang gliding, scuba, rock climbing, parachuting, vehicle racing, etc?
If so, what activities?
Life Insurance (only fill out this section if needed)
Amount of Life Insurance desired:
How many years you will need this coverage:
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10
15
20
25
30
Lifetime
Disability Insurance (only fill out this section if needed)
Do you have current disability insurance?
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Yes
No
Private Policy
Insurance Company
Monthly Benefit
Elimination Period
Length of Benefit
--
30
60
90
180
365
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1 year
3 years
5 years
7 years
Age 65
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30
60
90
180
365
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1 year
3 years
5 years
7 years
Age 65
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30
60
90
180
365
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1 year
3 years
5 years
7 years
Age 65
Employer Policy
Insurance Company
Monthly Benefit
Elimination Period
Length of Benefit
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30
60
90
180
365
--
1 year
3 years
5 years
7 years
Age 65
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30
60
90
180
365
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1 year
3 years
5 years
7 years
Age 65
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30
60
90
180
365
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1 year
3 years
5 years
7 years
Age 65
New or Additional Disability Coverage
Desired Monthly Benefit
Desired Elimination Period
Length of Benefit
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1 year
3 years
5 years
7 years
Age 65
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1 year
3 years
5 years
7 years
Age 65
Long Term Care Insurance (only fill out this section if needed)
Do you have current long term care insurance?
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Yes
No
Private Policy
Insurance Company
Monthly Benefit
Annual Premium
Length of Benefit
--
1 year
2 years
3 years
4 years
5 years
6 years
7 years
Lifetime
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1 year
2 years
3 years
4 years
5 years
6 years
7 years
Lifetime
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1 year
2 years
3 years
4 years
5 years
6 years
7 years
Lifetime
Employer Policy
Insurance Company
Monthly Benefit
Elimination Period
Length of Benefit
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30
60
90
180
365
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1 year
2 years
3 years
4 years
5 years
6 years
7 years
Lifetime
--
30
60
90
180
365
--
1 year
2 years
3 years
4 years
5 years
6 years
7 years
Lifetime
--
30
60
90
180
365
--
1 year
2 years
3 years
4 years
5 years
6 years
7 years
Lifetime
New or Additional Long Term Care Insurance
Desired Monthly Benefit
Elimination Period
Length of Benefit
--
30
60
90
180
365
--
1 year
2 years
3 years
4 years
5 years
6 years
7 years
Lifetime
--
30
60
90
180
365
--
1 year
2 years
3 years
4 years
5 years
6 years
7 years
Lifetime