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 Life Insurance 
Planning for the inevitability of death isn't comfortable for any of us. Unfortunately, the idea of our loved ones not being financially taken care of is an even worse thought. When one of the breadwinners in a family dies, it may be very difficult or even impossible for the survivors to support themselves. Why take the risk of putting your loved ones through a financial ordeal at such an emotionally difficult time? You can sleep easier knowing that, in the event of a death, your family needs will be taken care of.
Please complete the following questions to assist us in obtaining the most accurate term life insurance cost estimates. The more information you can provide, the better.
Gender:
Desired Amount of Coverage:
Premium Guarantee Period:
Tobacco: Smoke Cigarettes?
Have you used tobacco in any form in the last 24 months? Yes/No ie. Do you have an occasional cigar? If yes please note type of tobacco and date last smoked:
Family History:
Driving History:
Stress EKG: Has a test been performed in last 12 months?
If so was it normal?
Alcohol/Drugs: Any alcohol or substance abuse?
Aviation: Are you a commercial pilot or fly in private aircraft?
Activities: Have you participated or intend to participate in any hazardous activities or sports such as hang gliding hot-air ballooning ultra-light flying mountain or rock climbing motor vehicle or boat racing or scuba or sky diving?