A.D. DERN INSURANCE AGENCY, INC.

LIFE INSURANCE

QUOTE FORM

CUSTOMER INFORMATION *required fields in red

    
*Email Address
*Home Telephone
*Applicant's First Name
Cell Telephone

Mailing Address

Business Telephone
City State Zip County
Fax Telephone

Residence type (check one) Condo-owned Rented Home/Condo/Apartment Other
Number of years / months have you lived at this address?. . . .

CURRENT INSURANCE INFORMATION

Company Name

Policy Number
Renewal Date
Premium

PLEASE LIST FAMILY MEMBERS YOU WOULD LIKE US TO PROVIDE LIFE QUOTES
Name
Your Relationship
Gender M/F
Coverage Amount
Quote Policy Type
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4

PERSONAL UNDERWRITING INFORMATION - See Privacy Statement
 
Name

Birthdate
mm/dd/year

Smoker / Tobacco User Past 5 Years
Height
 Weight

SS #

No Dashes
Employer Name
Occupation & Duties
Feet
Inches
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Please explain all "YES" answers for any person in the Additional Notes Section below
# 1
# 2
# 3
# 4
1. Any history of HIV, AIDS, or ARC?
2. Any history of cancer, cardiovascular disease or diabetes?
3. Any Cardiovascular disease in a parent or sibling prior to their 61st birthday?
4. Have you lost a parent or sibling prior to their 61st birhday?
5. Any history of high blood pressure, or readings over 140/85 in the past 2 years?
6. Is your Cholesterol level over 220?
7. Are you currently taking or been on any medication within the past 3 yrs?
8. Have you quit smoking or quit using tobacco products within the past 5 years?
9. Ever receive a DUI violation in the past 7 years, or attended treatment facility for substance abuse?
10. Have you ever been declined coverage or offered a higher rate on any other application?
11. Have you participated in hazardous activities in the past 5 years such as Sky diving, Hang gliding, Rock climbing, Scuba diving, flown as a pilot, Car or Boat racing?
12. Are you a United States Citizen?

13. Are you in any branch of the Military?

ADDITIONAL NOTES - List question number & persons name with explanation for any "YES" answers



I/We acknowledge submission of this information is to receive a price quote for insurance, and that NO INSURANCE IS INFORCE until a completed and signed application with payment has been accepted by A.D. Dern Insurance Agency, Inc. and according to any specific Insurance Company requirements.

I agree to the above terms