Beneficial Insurance Marketing
Life and Health Insurance Quoting Information
_____________________________________________________________________________________________________________________
Please fill out this form as completely as possible. The more information that we have the more accurate your quote will be.
First Name :
Last Name :
Street Address :
City :
Zip :
County :
Home Phone :
Cell Phone :
Work Phone :
What is the best time to reach you :
Mornings 8am-12pm
Afternoon 12pm-4pm
Evenings 4pm-8pm
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
E-mail Address :
Person Who Referred You :
Family Information
Primary
Spouse
Child 1
Child 2
Child 3
Child 4
Name:
Date of
Birth:
Sex:
M
F
M
F
M
F
M
F
M
F
M
F
Occupation:
Height:
ft.
in.
ft.
in.
ft.
in.
ft.
in.
ft.
in.
ft.
in.
Weight:
lbs
lbs
lbs
lbs
lbs
lbs
Tobacco User
:
Y
N
Y
N
Have you had any
of the following
health conditions
check all that apply:
Heart
Heart
Heart
Heart
Heart
Heart
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Cancer
Cancer
Cancer
Cancer
Cancer
Cancer
HBP
HBP
HBP
HBP
HBP
HBP
HCL
HCL
HCL
HCL
HCL
HCL
COPD
COPD
COPD
COPD
COPD
COPD
Medical Information
Is any person to be insured currently on any prescription medications for ongoing health conditions? If "
Yes
" please list below. Also, please disclose
ANY
and
ALL
health
conditions that you have or have had in the past as well as approximate dates of treatment. This section needs to be completed for health and life insurance plans.
Primary
Yes
No
Spouse
Yes
No
Child 1
Yes
No
Child 2
Yes
No
Child 3
Yes
No
Child 4
Yes
No
Life Coverages
Primary
Spouse
Child 1
Child 2
Child 3
Child 4
Amount of
Coverage :
$
$
$
$
$
$
Type of
Coverage :
Term
Term
Term
Term
Term
Term
Universal
Universal
Universal
Universal
Universal
Universal
Whole
Whole
Whole
Whole
Whole
Whole
Final Expense
Final Expense
Tobacco User:
Y
N
Y
N
NA
NA
NA
NA
Disability:
Yes
No
Yes
No
NA
NA
NA
NA
Return of Premium:
Yes
No
Yes
No
NA
NA
NA
NA
Waiver of Premium:
Yes
No
Yes
No
NA
NA
NA
NA
AD&D:
Yes
No
Yes
No
NA
NA
NA
NA
Critical Illness:
Yes
No
Yes
No
NA
NA
NA
NA
Child Rider:
NA
NA
Yes
No
Yes
No
Yes
No
Yes
No
Medical Coverage
Primary
Spouse
Child 1
Child 2
Child 3
Child 4
Medical Coverage:
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Please check desired coverages below for your health plan.
Low Deductible $0 - $5,000
High Deductible $5,000 - $25,000
Accident Coverage
Prescription Drug Coverage
Preventative
Critical Illness
Maternity
Dental
Vision
Short Term Convalescent
Term Life
Other (Describe below)
Please describe
other
desired
coverages (not listed above) here:
Additional Information
Please give any additional comments or information that you feel is appropriate for this quote. If you have additional children or other information where there was not enough
space please enter them here.
By pressing the submit button below you are giving Beneficial Insurance Marketing and its agents permission to contact you concerning the products and information that
you have requested above. It is also understood that the information being submitted will be used exclusively for information, quoting, and underwriting purposes and Will
Not be sold or otherwise distributed to any outside entities without your expressed written or verbal consent.