This paragraph contains a brief description of the product ...

Key Benefits

  • Benefit 1
  • Benefit 2
  • Benefit 3

Information Request Form

Select the items that apply, and then let us know how to contact you.

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Name:

Title:

Company:

Phone:

Address:

E-Mail:

Health Insurance Quote

If you are interested in receiving a free quote from one of our sales representatives, please submit the follow information. You will be contacted with in 24 hours. Thank you.

Part 1: Personal Information

Name:

Occupation:

Address:

City:

State:

Zip:

Birthdate (mm/dd/yy):

Weight:

Height:

Part 2: Activities & Health Questions

Has the Insured or Proposed Insured....

A)....used nicotine or products containing nicotine within the last 12 months?

Yes   No

    

B)....ever sought medical advice or been treated for or been diagnosed as having any kind of physical, mental, or emotional disease, disorder, or problem? ( if yes, then please explain in detail below.)

Yes   No

    

C)....ever been diagnosed by a member or the medical profession as having or receiving treatment for AIDS or AIDS related complex?Yes   No

    

D)....ever tested positive for HIV? (North Dakota residents need not respond. California Residents need only reveal results of HIV tests taken for the purpose of obtaining insurance.)Yes   No

    

E)....ever used alcohol to a degree that required treatment or advice from a Physician or medical practitioner?Yes   No

    

F)....ever attempted suicide?Yes   No

    

G)....gained or lost more than 20 in the last year? (if yes, then give amount and reason for loss or gain below.)Yes   No

    

H)....had any surgical operation preformed or recommended?Yes   No

    

I)....been diagnosed or treated for a blood disorder or anemia within the last 10 years?Yes   No

    

J)....been currently taking any medication or receiving treatment?Yes   No

    

K)....submitted to any tests (excluding HIV), taken medication, or received any treatment within the last 6 months?Yes   No

    

L)....sought medical advice or been treated for cholesterol or triglycerides with in the last 5 years?Yes   No

    

M)....had or been advised to have a X-ray, blood tests (excluding HIV), mammogram, prostate study, or electrocardiogram with in the last 5 years?Yes   No

    

N)....seen a Physician, been under observation, care, or treatment in any hospital or treatment facility? (Wisconsin residents need not disclose HIV test results received at alternate test sites.)Yes   No

    

O)....during the last 3 years, used or been treated for use of any type of narcotic or drug, except as prescribed by a Physician? (if yes, then please explain below including; name of insured/proposed insured, type of drug(s), frequency of use, and date of last use.)Yes   No

    

P)....had any application for life, accident, or health insurance? Yes   No

    

Q).... had a reinstatement of any type of policy declined, postponed, cancelled, or issues on a modified basis?Yes   No

    

R)....flown in the past 2 years other than a fare paying passenger on a commercial airline or contemplate doing so in the future? (if yes, then please complete the section below.)

 Insured/Proposed Insured Name               Type of License              Type of Aircraft   

            

Total Number of Solo Hours                Date of First Flight           Date of Last Flight

                                 

Hours of Flying time as a Pilot, Student Pilot, or Crew Member during the ...

        ...last 2 years  ...last 12 months  ...next 12 months

Private:                                                     

Commercial:                                            

Military:                                                     

Yes   No

    

 

 

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Last modified: 03/02/05