Life Insurance Form

GENERAL INFO
Applicant
Spouse/Co-applicant
NAME:
PHONE:
ADDRESS:
DATE OF BIRTH:
GENDER:
SMOKING HISTORY:
HEIGHT:
FEET INCHES FEET INCHES
WEIGHT:
E-MAIL:
DESIRED COVERAGE
 
TYPE OF COVERAGE:
AMOUNT OF COVERAGE:
COVERAGE WILL BE:
QUALIFYING QUESTONS:

We have many carriers who specialize in high risk policies. Please answer the following questions as accurately as possible.

QUESTION 1:

DO YOU PARTICIPATE IN RACING, SKY DIVING, HANG GLIDING, MOUNTAIN CLIMBING OR ANY OTHER HAZARDOUS ACTIVITY OR OCCUPATION?:

DOES THE CO-APPLICANT PARTICIPATE IN RACING, SKY DIVING, HANG GLIDING, MOUNTAIN CLIMBING OR ANY OTHER HAZARDOUS ACTIVITY OR OCCUPATION?:

QUESTION 2:

HAVE YOU BEEN UNDER THE TREATMENT OF A DOCTOR WITHIN THE PAST 3 YEARS FOR A HEART ATTACK, STROKE, CANCER, DIABETES, BYPASS SURGERY, EMPHYSEMA, KIDNEY, CORONARY ARTERY OR LIVER DISEASE, CHRONIC BRONCHITIS OR CHRONIC ASTHMA?:

HAS THE CO-APLICANT BEEN UNDER THE TREATMENT OF A DOCTOR WITHIN THE PAST 3 YEARS FOR A HEART ATTACK, STROKE, CANCER, DIABETES, BYPASS SURGERY, EMPHYSEMA, KIDNEY, CORONARY ARTERY OR LIVER DISEASE, CHRONIC BRONCHITIS OR CHRONIC ASTHMA?:

PLEASE SEND ME MONEY SAVING OFFERS ON AUTO INSURANCE
AUTO POLICY EXPIRATION DATE (if box checked above):
CURRENT AUTO INSURANCE CARRIER:
 

By submitting this form you agree that the above information is complete and correct. Additionally, some states may require your expressed written consent for your medical information to be released to others. By providing any medical information to us you are explicitly waiving your right to privacy and granting us your permission to share this information with others for the purpose of providing insurance quotations.

 


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Copyright 2010 BMI Insurance Inc. :: Ben Miller Insurance Agency, Inc, Lic# 0E14637