Please fill out the information needed to provide you with a Life Insurance Quote.

Enter your State	Birthdate	Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Sex- Male Female
Height	Weight (with clothes on)		When did you last use nicotine?
Coverage Amount Desired: $50,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000 $550,000 $600,000 $650,000 $700,000 $750,000 $800,000 $850,000 $900,000 $950,000 $1,000,000			Select One Never Last 12 months: Cigarettes Last 12 months: Occasional Cigar 1-5 mo Last 12 months: Frequent Cigar- more than 1/week Last 12 months: Nicotine Substitute (patch, gum, etc) None in the last year None in the last 2 years None in the last 3 years None in the last 4 years None in the last 5 years

First Name		Last Name
Address		Address 2
City		Zip
Email
Day Phone		Evening Phone

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Do you recall your last Blood Pressure Reading?
Do you have to take Blood Pressure Medication?	Select One Yes No
Do you recall your last Cholesterol Level?
Do you have to take Cholesterol Medication?	Select One Yes No
Any family members (parents or siblings) diagnosed with Cardiovascular Disease (heart disease or stroke) or cancer before age 60?	Select One Yes No
Have you ever been rated or declined by any life insurance company before?	Select One Yes No
Has any doctor recommended any medical tests or procedures that you have not yet completed?	Select One Yes No
Do you intent to fly as a Private Pilot?	Select One Yes No
Within the past 5 years, have you received 3 or more moving violations, had your drivers license suspended, been convicted of reckless driving or driving while under the influence?	Select One Yes No

Please Select the Medical Conditions below where you have needed medication over the past 7 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

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