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----FREE QUOTE----
2. LIFE INSURANCE
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State:  
Birth Date:  
Sex:   Male  Female 
Height:     Weight (with clothes on):    
Coverage Amount:  
  We recommend that each household breadwinner carry
  ten times their annual income in term life insurance.
First Name:  Last Name: 
Street Address:  City:    Zip:
Day Phone:  ( ) - Ext Evening Phone:  ( ) - Ext
E-Mail: 
When did you last use tobacco or nicotine?
Do you intend to fly as a Private Pilot? No Yes
Within the last 5 years, have you been convicted of either reckless
driving or driving while under the influence, received 3 or more
moving violations or had your license suspended/revoked? 		No Yes
Do you recall your last
blood pressure reading?
Systolic  
Diastolic

 

Are you taking blood pressure medication?

No Yes
Do you recall what your last cholesterol level was?
 Are you taking cholesterol medication? No Yes

 

Family history is very important.  Any family (parents or siblings) diagnosed with heart disease or cancer before age 60?

No Yes
Have you ever been rated up or declined by any life insurance company? No Yes
Has any doctor recommended any medical test or procedure
that you have not yet completed? 		No Yes
For what medical conditions have you taken prescription drugs over the past 12 years?
 Alzheimer's    Anxiety, ADD, ADHD or Depression    Artery (Coronary) Disease
 Asthma    Cancer (Other Than Skin)    Colitis or Ileitis
 COPD    Crohn's Disease    Diabetes
 Emphysema    Epilepsy    Heart Disease or Abnormal EKG
 Hepatitis or Liver Disease    HIV    Kidney Disease
 Leukemia    Melanoma    Mental Illness
 Mitral Valve Prolapse    Multiple Sclerosis    Parkinson's Disease
 Prostate Cancer    Rheumatoid Arthritis    Sleep Apnea
 Stroke    Vascular Disease    
Within the last 7 years, have you had any of the following conditions?
 Alcoholism    Cancer (Skin Only)    Drug Abuse or Addiction
 Gastric/Peptic Ulcers    Recurrent Kidney Stones    
Other
Privacy Clause  
At L & R insurance we are committed to protecting your privacy.  We will not sell or give your personal information to anyone other than a insurance agent or broker at your request.     
 
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