First
name*
MI
Last
name*
Address
*
City*
State*
Select
MO
IL
Zip*
Marital
Status
Select
Single
Married
Divorced
Widowed
Other
Best
way to be contacted?*
Select
e-mail
phone call
letter
fax
Phone
number (add area code)*
Best
time to call*
a.m.
p.m.
Fax
number
Work
number
E-mail
address *
Occupation
How
long
Select
Years
Months
Additional
Comments:
Health Information
Gender
Select
Female
Male
Date
of Birth (mm/dd/yyyy)
Weight:
Your
height
Feet
1'
2'
3'
4'
5'
6'
7'
8'
9'
Inches
1"
2"
3"
4"
5"
6"
7"
8"
9"
10"
11"
Please
describe your occupation
If
you currenly smoke cigarettes, how many packs daily?
I'm a non-smoker
Less than 1 pack
1 pack
2 packs
3 packs
4 packs
More than 4 packs a day
I
used to smoke, but quit:
Select
I do not smoke
Over 5 years ago
Over 4 years ago
Over 3 years ago
Over 2 y ears ago
Over 1 year ago
Does
your spouse smoke
No
Yes
Select
all that apply:
Select
I do not smoke
Cigarettes
Smoke cigars
Smoke a pipe
Chew tobacco
Chew nicotine gum
A Quit Smoking Program
Trying to quit (by self)
Other
Select
I do not smoke
Cigarettes
Smoke cigars
Smoke a pipe
Chew tobacco
Chew nicotine gum
A Quit Smoking Program
Trying to quit (by self)
Other
Select
I do not smoke
Cigarettes
Smoke cigars
Smoke a pipe
Chew tobacco
Chew nicotine gum
A Quit Smoking Program
Trying to quit (by self)
Other
if OTHER(s) please explain
Type
of insurance interested in
Select
20 year guaranteed Level Permium Term
15 year guaranteed Level Permium Term
10 year guaranteed Level Permium Term
5 year guaranteed Level Permium Term
1 year ART (Annually Renewable Term)
Universal
Whole
Variable
Other term products
Amount
$
Are
you a private pilot or student pilot? If yes, please explain type
of rating, type of aircraft, total number of hours of experience,
and number of hours flown per year (IFR, VFR, single-engine, multi-engine,
etc.):
Select
No
Yes
Do
you engage in scuba diving, sky diving, rock climbing, motorized
racing, or any other hazardous avocation or occupation? If yes,
please explain:
Select
No
Yes
Have
you been concicted of drunk driving in the past 7 years?
No
Yes
Has
your driver's license been suspended or revoked in the past 7
years?
No
Yes
Been
convicted of 2 or more moving violations in the the past 3 years?
No
Yes
Ever
been convicted of, or are you now awating trail for a felony?
No
Yes
In
the past 5 year, have you filed for bankruptcy?
No
Yes
Are
you a US citizen?
No
Yes
Additional
Information:
