Western Benefits InsuranceAgency: Life Insurance Quote

Life Insurance Quote

Name:

Address:

City:

State:

Zip:

Phone:

E-Mail:

Best time to contact you: Daytime Evening
Best place to contact you: Work Home
Sex: Male Female
Date of birth: Month/Day/Year / /
Your Height:    Feet   Inches
Your Weight:   pounds
    
How much life insurance would you like us to quote?

What type of life insurance are you looking for?

Description of other type of coverage you are looking for:

The coverage to be quoted will likely be:
new coverage (I have none now)
additional coverage
replacement of existing coverage

Tobacco Usage:
I have never smoked.
I used to smoke, but I quit in
I smoke no more than one pack of cigarettes per day.
I smoke more than one pack of cigarettes per day.
I smoke cigars.
I smoke a pipe.
I chew tobacco.
I am on "the Patch."

Do you take any prescription medication? Yes No
If yes please explain.

Do you have any health problems? Yes No
If yes please explain.

Are you a private pilot? Yes No
If yes, please explain type of rating, type of aircraft, total number of hours experience, and hours flown per year:

Do you engage in scuba diving, sky diving, rock climbing, motorized racing, or other hazardous avocation or occupation? Yes No
If yes, please explain in detail:

Have you been convicted of drunk driving, or had your driver's license suspended or revoked in the past five years? Yes No
If yes, please explain in detail:

Have you been convicted of three or more moving violations in the past three years? Yes No
Have you ever been convicted of a felony? Yes No
If yes, please explain dates, charges, and details:

In the past 10 years, I have been advised regarding, or been treated for:
Hypertension Heart Disease Cancer Diabetes
Stroke Alcohol or Drugs AIDS Other
If you checked any of the above, please explain:

Did any of your grandparents, parents or siblings have heart disease or cancer, prior to age 65? Yes No
If yes, please explain:

Any other Questions or Comments?

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