Premier Services - The Insurance Experts

Life Insurance Application Form

Name:

Address:

City, State, Zip Code:

Phone:

Fax:

E-Mail:

Sex:

Date of Birth (MM/DD/YY):

Do you use tobacco?

If so, how long since using tobacco?

Height:

Weight:

Occupation:

Do you pilot or have duties on an aircraft? Yes No

Do you participate in any hazardous sports or activities such as parachute jumping, hang gliding, race car driving, scuba diving, etc.? Yes No

If either of the above two questions are YES, then please explain:

Amount of coverage needed:

Job description:

Describe any health problems:

Are you on any medication? If so, please list medication and reasons:

Any cancer, heart disease, kidney disease, high blood pressure or diabetes within the immediate family?
Yes No
If yes, please explain below:

In the next two years, any plans to live or travel outside the United States? If yes explain

Have you ever had any life or health policy rated, canceled or declined? If yes, explain:

In the last five years, have you ever been convicted of driving under the influence of drugs or alcohol? If yes explain:

Within the last three years have you had three or more traffic citations, or had your license suspended or revoked? If yes explain:

Do you have quotations from other companies? Yes No

Would you like a quote from us for the same coverage for easy comparison? Yes No

Who is the insurance company?

What was the price quoted?

What is the amount of death benefit?

How did you hear about us?

Additional Comments: