$250,000

$500,000

$1,000,000

Age

Male

Female

Male

Female

Male

Female

30

$140

$132

$228

$175

$361

$324

40

$175

$156

$312

$252

$456

$444

50

$384

$288

$684

$516

$1284

$936

60

$900

$552

$1608

$1044

$3108

$161

First Name:

Last Name:

Address:

City:

State:

Zip:

Day Phone:

(xxx-xxx-xxxx)

Evening Phone:

Fax:

(xxx-xxx-xxxx)

Email:

Male or Female:

Date of Birth:

(mm/dd/yy)

Type of Insurance:

30 Yr Guaranteed Level Term20 Yr Guaranteed Level Term15 Yr Guaranteed Level Term10 Yr Guaranteed Level TermUniversal Life2nd-to-die (Survivorship Insurance)

Insurance Amount:

$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$1,500,000$2,000,000$2,500,000$3,000,000$3,500,000$4,000,000$4,500,000$5,000,000above $5,000,000

Height:

Weight:

lbs

Tobacco Use:

(Please Select)Have never smoked or used nicotineUsed to smoke, but quit less than 1 yr agoUsed to smoke 1-3 yrs agoUsed to smoke 3-5 yrs agoUsed to smoke over 5 yrs agoCurrently smoke cigarettesOther nicotine use-cigars/pipe/chew/patch

Health Status:

(Please Select)Excellent: trim and athletic, no medicationsGood: no infirmities and no medicationsFair: slightly overweight or taking medicationPoor: have/had a serious health condition

Health conditions?
YesNo

Explain:

Prescription medications?
YesNo

Explain:

Do you engage in any hazardous activities?
(i.e. scuba,skydiving,private pilot,etc.)
YesNo

Explain:

Did your parents or siblings have
heart disease or cancer prior to age 60?
YesNo

Explain: