Life insurance issued for a stated temporary period of time. These policies provide benefits in the event of death, but they generate no cash value. If you have a limited amount to spend, and only need insurance for a finite period of time, you may be able to get more coverage by buying term insurance than by buying cash value insurance. Standard life insurance is for those who fulfill the physical, occupational, and other requirements on which most of the company’s policies are issued. Someone whose requirements are more favorable may be eligible for a "Preferred Risk."   When the applicant's characteristics are less favorable, they may be characterized as "Rated" or refused coverage altogether.

General Information:
 
1.  *First Name:  
2.  *Last Name:  
3.  *Phone:  
4.  *Email:  
5.  Address:  
6.  Address:  
7.  City:  
8.  *State:  
9.  *Zip Code:  
9.  County:  
The following questions concern the type of life insurance coverage you are requesting . Please answer them as accurately as possible.
1) What type of Term life insurance are you seeking: 1 Year Annually Renewable
5-Year Guaranteed Level Premium
10-Year Guaranteed Level Premium
15-Year Guaranteed Level Premium
20-Year Guaranteed Level Premium
25-Year Guaranteed Level Premium
30-Year Guaranteed Level Premium
Not Sure
 
2) Please indicate the coverage amount:
3) What is your gender? M F
4) What is your date of birth:
MM DD YYYY
/ /
5) Please provide your height: ft. in.
6) What is your weight? lbs.
7) Please indicate your marital status:
8) What is the highest Level of education you completed:
9) What is your current employment status:
10) Please select the industry which best describes your occupation:
11) How long have you been at your present job? Years Months
To help us ensure that our search delivers the most competitive quote for your insurance needs, we’ll need some information about your day-to-day lifestyle, your medical history and your current health status. Please continue by answering the following set of questions to the best of your knowledge
12) In the past five years, have you used any form of tobacco or a nicotine substitute?
13) If you have, what forms of tobacco did or do you use? Smoke Cigarettes
Smoke Cigars
Smoke A Pipe
Chew Tobacco
Chew Nicotine Gum
'The Patch'
14) If you currently smoke cigarettes, how many packs do you smoke per day?
15) Have you used any form of alcohol in the past five years? No Yes
16) If you have, what do you usually drink? Beer
Wine
Liquor
17) Have you received a DUI Or DWI in the last five years? Yes No
18) Have you been hospitalized in the last five years? Yes No
19) Are you currently taking any prescription medications? Yes No
20) Are you a U.S. citizen? Yes No
21) Have you lived outside the United States anytime during the last three years? Yes No
22) In the future, do you plan to leave the United States for travel or change of residence? Yes No
23) To your knowledge, is there a history in your family (grandparents, parents or siblings) of cardiovascular disease before the age of 60? Yes No
24) During the last 2 years, have you worked in any type of hazardous, occupation? (for example underground mining, high-rise construction, work or explosives handling) Yes No
25) Are you an active member of the military or military reserve?
26) Have you flown on an aircraft as a pilot, co-pilot or crew-member, within the last 3 years?
27) Do you participate in any risky activities such as racing, scuba, diving, sky diving, mountain climbing, para-sailing or ultra light, flying? Yes No
28) Have you suffered any health symptoms related to the conditions listed below? If so, please check the box next to the specific condition(s) that you have been advised you had or have been treated for:
Central Nervous System Skin, Bones or Muscles Mental Health, Drug Abuse
Epilepsy
Multiple Sclerosis
Alzheimer's Disease
Cancer 		Rheumatoid Arthritis
Melanoma
Cancer 		Alcoholism
Drug Abuse
Mental Illness
Depression
Digestive System Respiratory System Circulatory System
Chronic Kidney Disease
Liver Disease
Kidney Stones
Gastric/Peptic Ulcers
Ulcerative Colitis or Ileitis
Neurogenic Bladder
Bowel Incontinence
Diabetes Mellitus
Cancer 		Asthma
Emphysema
Chronic Bronchitis
COPD
Cancer 		Coronary Artery Disease
Vascular Disease
High Blood Pressure
Stroke
Elevated Cholesterol
Cancer
HIV
29) What range best describes your approximate household income:
30) Do you own or rent your residence:
31) Time at current residence:
32) Please describe your credit history:
33) Best Time To Contact:
34) Additional Comments:
Please provide any additional information you feel is pertinent to the insurance coverage you need.

 
Copyright 2003 [Your Company Name.LTD]. All rights reserved