General Information Name: Address: City: State: ZIP: County: Email: Phone Day: Night: Best time to call: AM PM About Yourself: Date of Birth Sex Marital Status Occupation Height Weight M F M S lbs Have you ever used tobacco in any form: Yes No If yes, how long since you quit? Have you had any of the following health conditions: Heart Cancer Diabetes HBP Are you currently on any prescription medications for ongoing health conditions? Yes No If yes, please list: Please DISCLOSE any and all health conditions you have (or had in the past): Do you wish to include your spouse on this coverage quote? Yes No About Your Spouse (Only if he or she is to be covered): Name Date of Birth Sex Occupation Height Weight M F lbs Have they ever used tobacco in any form: Yes No If yes, how long since they quit? Have they had any of the following health conditions: Heart Cancer Diabetes HBP Are they currently on any prescription medications for ongoing health conditions? Yes No If yes, please list: Please DISCLOSE any and all health conditions they have (or had in the past): Do you wish to include your child(ren) on this coverage quote? Yes No Child # 1 (Only if he or she is to be covered): Name Date of Birth Sex Occupation Height Weight M F lbs Have they ever used tobacco in any form: Yes No If yes, how long since they quit? Have they had any of the following health conditions: Heart Cancer Diabetes HBP Are they currently on any prescription medications for ongoing health conditions? Yes No If yes, please list: Please DISCLOSE any and all health conditions they have (or had in the past): Do you wish to include another child on this coverage quote? Yes No Child # 2 (Only if he or she is to be covered): Name Date of Birth Sex Occupation Height Weight M F lbs Have they ever used tobacco in any form: Yes No If yes, how long since they quit? Have they had any of the following health conditions: Heart Cancer Diabetes HBP Are they currently on any prescription medications for ongoing health conditions? Yes No If yes, please list: Please DISCLOSE any and all health conditions they have (or had in the past): Do you wish to include another child on this coverage quote? Yes No Child # 3 (Only if he or she is to be covered): Name Date of Birth Sex Occupation Height Weight M F lbs Have they ever used tobacco in any form: Yes No If yes, how long since they quit? Have they had any of the following health conditions: Heart Cancer Diabetes HBP Are they currently on any prescription medications for ongoing health conditions? Yes No If yes, please list: Please DISCLOSE any and all health conditions they have (or had in the past): Do you wish to include another child on this coverage quote? Yes No Child # 4 (Only if he or she is to be covered): Name Date of Birth Sex Occupation Height Weight M F lbs Have they ever used tobacco in any form: Yes No If yes, how long since they quit? Have they had any of the following health conditions: Heart Cancer Diabetes HBP Are they currently on any prescription medications for ongoing health conditions? Yes No If yes, please list: Please DISCLOSE any and all health conditions they have (or had in the past): Coverages Please select the following coverages: LIFE Coverages Please select if interested in LIFE coverage. Amount of Coverage (self): $ Amount of Coverage (spouse): $ Amount of Coverage (per child): $ Type of Coverage: Term Whole Universal Disability Income Monthly Amount: Waiting Period: 30 Days 60 Days 90 Days 180 Days 365 Days Long Term Care Coverage Monthly Amount: Waiting Period: 30 Days 60 Days 90 Days 180 Days 365 Days Coverage for: Self Spouse Child #1 Child #2 Child #3 Child #4 HEALTH Coverages Please select if interested in HEALTH coverage. Amount of Deductible: $250 $500 $750 $1,000 $2,500 $5,000 Co-payment plan: 80/20 70/30 50/50 Do you prefer a PPO option? Y N Maternity: Y N Preventative: Y N Coverage for: Self Spouse Child #1 Child #2 Child #3 Child #4 Additional Comments: Please give any additional comments about the coverage you desire:
Do you wish to include your spouse on this coverage quote? Yes No
Do you wish to include your child(ren) on this coverage quote? Yes No
Do you wish to include another child on this coverage quote? Yes No
