HOURS
Monday-Friday:
8:00am - 5:00pm
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Evenings & Weekends:
By appointment


Phone:      419.523.4500      
Toll Free:  800.686.4500      
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Fax:          419.523.0045      




Please complete and submit this
questionnaire so a proposal/quote
can be provided to you.

  

Health and/or Life Insurance Questionnaire

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* indicates "required information"
* indicates "required information" when applicable
   
Type of
Quote Desired:		 * Health Insurance Life Insurance Both
Personal Information:
* indicates "required information"
* indicates "required information" when applicable
Applicant Name: * Required.
Age: * Required.
Gender: * Male    Female
Height:
* feet inches
Weight: * lbs.
Smoking status: * NonSmoker    Smoker
Spouse Name: *
Age: *
Gender: * Male    Female
Height:
* feet inches
Weight: * lbs.
Smoking status: * NonSmoker    Smoker
Address: *
Zip Code: *
Phone #: * Required.
Cell #:   
Fax #:   
Email Address: * Required.
Children:
      
  Name:    Age:
  Name:    Age:
  Name:    Age:
  Name:    Age:
  Name:    Age:
Life Insurance Information:
* indicates "required information"
* indicates "required information" when applicable
*How much life insurance are you applying for?
*Indicate the type of insurance for which you are applying:

Whole Life
Term Life
Not sure
Medical Insurance Information:
* indicates "required information"
* indicates "required information" when applicable
*Are you currently pregnant, an expectant parent, or in the process of adoption (even if not applying for this insurance)?
Yes  No
*During the past 12 months, have you, or anyone applying for coverage:
a. taken any prescription medication or have been prescribed medication by a physician?		 Yes  No
*If yes, please list the medication and for whom it was prescribed:
*During the past 12 months, have you, or anyone applying for coverage:
a. been recommended for surgery,
diagnostic testing, or medical treatment?		 Yes  No
*If yes, please list recommendation(s) and for whom the recommendation(s) were made:
*In the past 10 years, have you, or anyone applying for coverage:
a. been diagnosed, or received treatment for any medical conditions that have required hospitalization or
b. been diagnosed or treated for any other medical condition?		 Yes  No
*If yes, please list each diagnosis/ treatment and for whom the diagnosis/ treatment was made:
*Have you, or anyone applying for coverage, ever been declined for insurance due to health reasons? Yes  No
*If yes, please list the name of the person(s)for which insurance was declined:
*Do you want full maternity coverage? Yes  No
*Do you want a dental quote?  Yes  No
*Do you currently have medical coverage?   Yes  No
*If yes, list Insurance Carrier:       
*If yes, was the coverage continuous for the last 12 months?
(This may enable you to get pre-existing coverage for any new plans)		 Yes  No
*If the coverage was not continuous, how long were you without insurance?
Contact Preferences:
* indicates "required information"
* indicates "required information" when applicable

*How would you like us to reply back to you?