First Name              

Middle Initial            

Last Name                    

Name of Company

How Many Employees     Years In Business

Company Street Address

City  State  Zip 

Describe Priorities or Concerns

Types of Coverage Interested In.

  Accident   Cancer  Critical Illness Disability Income
  Medical Bridge   Term Life   Universal Life

Date of Birth         Height       Weight      

    Smoker      Yes     No     

   Have you used any  tobacco in the last 5 Years  Yes    No    

   If Yes list type and last time used

   High Blood Pressure  Yes    No     High Cholesterol  Yes    No  

   Heart Attack, Stroke or Cancer    Yes   No   

   If Yes What Describe What & When

   Diabetes    Yes     No

   Treated for or taking Rx's for any other Illness, Describe what & when

   Have you been hospitalized for anything in the last 5 years   Yes  No 

   If Yes on Hospitalized Describe briefly for what and when 

   Occupation       

Home Street Address            

City             State       Zip   

Phone Required for Quotes and possible interview if more details are needed.    

Primary  Phone           Work Phone:

     Alternate Phone

     Best time & Place  to  call

     eMail   

  What is the degree of  importance and urgency on a scale of  1 to 10 (a ten meaning highest priority)