Canyon Insurance Agency :: Life Insurance Quote

Type of quote:

Full name: (required)

Street address:

City, State & Zip:

E-Mail address: (required)

Day telephone: (required)

Eve telephone:

Fax:

Best time to reach you:

Requested effective date:

(mm/dd/yyyy)

Amount of coverage you wish to obtain:

or other amount: $

Do you have insurance now?

(if not, skip this section)

Insurance company name:

(not your agent or broker)

Policy expiration date:

(mm/dd/yyyy)

Face value of existing policy:

Monthly premium amount ($):

Term:

Your gender:

Male Female

Your date of birth:

(mm/dd/yyyy)

Your height and weight:

Height: Weight:

Do you smoke?

Yes No

If NO, how long have you been smoke-free?:

years

Please check if you have had or been treated for any of the following conditions :
(Check all that apply)

High blood pressure
Cancer
High cholesterol
Heart problems
Depression and/or anxiety
Diabetes
Alcohol or substance abuse
Asthma
Other significant issues

Have your parents or siblings been treated for cancer, diabetes, or cardiovascular disorders prior to age 60?
Yes (if YES, describe in the box to the right)
No

Do you currently take medications?
Yes (if YES, describe in the box to the right)
No

Are there any health problems that you think would impact the rate?
Yes (if YES, describe in the box to the right)
No

Have you had 2 or more moving violations in the last 2 years or any DUI's in the last 5 years?
Yes (if YES, describe in the box to the right)
No

Was any coverage declined, cancelled or non-renewed within the past 5 years?
Yes (if YES, describe in the box to the right)
No

Do you want coverage for your spouse and/or children?

Yes No (If NOT, skip this part.)

Your spouse's gender:

Male Female

Your spouse's date of birth:

(mm/dd/yyyy)

Your spouse's height and weight:

Height: Weight:

Does your spouse smoke?

Yes No

If NO, how long has your spouse been
smoke-free?:

years

Please check if your spouse has had or been treated for any of the following conditions : (Check all that apply)

High blood pressure
Cancer
High cholesterol
Heart problems
Depression and/or anxiety
Diabetes
Alcohol or substance abuse
Asthma
Other significant issues

Have your spouse's parents or siblings been treated for cancer, diabetes, or cardiovascular disorders prior to age 60?
Yes (if YES, describe in the box to the right)
No

Does your spouse currently take medications?
Yes (if YES, describe in the box to the right)
No

Are there any health problems that you think would impact the rate?
Yes (if YES, describe in the box to the right)
No

Has your spouse had 2 or more moving violations in the last 2 years or any DUI's in the last 5 years?
Yes (if YES, describe in the box to the right)
No

Was any coverage declined, cancelled or non-renewed within the past 5 years?
Yes (if YES, describe in the box to the right)
No

Age

Height

Weight

Child #1

Child #2

Child #3

Child #4

COMMENTS, QUESTIONS OR ADDITIONAL INFORMATION WE SHOULD KNOW

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