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Life Insurance Quote Form
Name:
Address:
E-Mail Address:
Phone:
>
I am requesting information about
Life Insurance
Term & Permanent
Mortgage and Family Protection
Health Insurance
Major Medical and Medicare
Insurance Amount:
>
100,000
200,000
250,000
300,000
400,000
500,000
600,000
700,000
750,000
800,000
900,000
1,000,000
2,000,000
3,000,000
Duration:
>
10 years
15 years
20 years
30 years
To age 95
Date of Birth:
Gender:
>
Male
Female
Tobacco Use (past 3 yrs):
>
No
Smoker
Smokeless Tobacco
Health Class:
>
Preferred Plus
Preferred
Standard
Sub-Standard
See Below to Determine
Health Class
Determine Your Health Class
Preferred Plus.
Excellent health. Good cholesterol ratios. No medications and no premature family diagnosis of heart disease or cancer.
Preferred.
Good health. Normal weight. No medications and no premature family death of heart disease or cancer.
Standard.
Fair health. Some major health conditions allowed.
Sub-Standard
. Poor health or obese. If insurable, your premium could be several times more than standard rate.
In Stock:
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