| Proposed
Insured's Questions |
| First Name: |
|
|
| Last Name: |
|
|
| Age: |
|
|
| Gender: |
|
Male
Female |
| Height: |
|
|
| Weight: |
|
|
| Last Time Tobacco was used: |
|
|
| Amount of coverage: |
|
|
| Date of birth: |
|
|
| Has proposed insured ever
been told that you have or been treated for: diabetes, cancer, heart
disease, alcoholism or drug abuse? |
|
No
Yes |
Has proposed insured ever been told you have
or been treated for high blood pressure?
|
|
No
Yes |
| What Type of
Life Insurance are you interested in? |
|
|
| How long is coverage needed? |
|
|
| Does the proposed insured currently have life
insurance? |
|
No
Yes - if Yes, Premium
|
| To
receive a larger discount would you consider also insuring your
cars or home? |
|
No
Yes |
| Do you have any Questions or Suggestions? |
|
|
Refer
a Friend 
