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LIFE INSURANCE

 

 

You Can Save up to 60% On Your Life Insurance!!

 

YOU ARE UNLIKELY TO FIND LOWER RATES ANYWHERE ELSE!!

 

Complete the form below as accurate as you can and we'll do the rest.

First Name
Last Name
Street Address
City
State CA
Zip Code
Day Phone
Evening Phone
Fax Number
E-mail Address
Best time to call:
Who is this quote for?
Gender
Birthday 19 
Height feet inches 
Weight lbs. 
How much insurance 
do you want?
What type of insurance 
do you want?
Purpose of insurance:
Amount of insurance 
in force now:		  

Current insurance carrier if known? 

How much are you 
currently paying per year?		 $ 
Please indicate Tobacco/Nicotine Use:  

If you used to smoke and have quit please indicate when.  

Please list any medications 
and dosage 
(leave blank if none)
Have you ever been advised or treated for any of the following (Check all that apply)
AIDS 
Alcohol or Drugs 
Alzheimer's Disease 
Asthma 
Cancer 
Cholesterol 
Chronic Obstructive Pulmonary Disease 
Depression 
Diabetes		 Heart Disease  
Hypertension 
Kidney or Liver Disease 
Mental Illness 
Stroke 
Ulcerative Colitis or Ileitis 
Vascular Disease 
Other
 
If you checked any of the above, please explain date of onset or beginning of treatment, diagnosis, and current status:
 
Are you a private pilot or student pilot? Yes No  

If yes, please explain type of rating, type of aircraft, total number of hours of experience, and number of hours flown per year (IFR, VFR, single-engine, multi-engine, etc.): 

Do you engage in scuba diving, sky diving, rock climbing, motorized racing, or any other hazardous avocation or occupation? Yes No  

If yes, please explain. 

Have you been convicted of drunk driving (past 5 years), or had 2 or more moving violations (past 3 years), or had your driver's license suspended or revoked (past 10 years)? Yes No  

If yes, please explain. 
Have you ever been convicted of, or are you awaiting trial for a felony? Yes No  

If yes, please explain. 

In the past 5 years, have you filed for bankruptcy? Yes No  

If yes, please explain including date of discharge. 

Did any of the parents or siblings of the proposed insured have cardiovascular disease or cancer, prior to age 60? Yes No  

If yes, please explain. 

Are you a United States citizen:  

If no, what country? 

 

IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent. Also, in no way does submission of this form obligate anyone to any contract.

 

 

eInsuranceServices.com is a domain and web address owned by

InsuranceGuys Insurance Services, Inc.
California License# 0B53906 / Arizona License# 137235

P.O. Box 6823  ~  Santa Barbara, CA 93160-6823

Office Toll Free: (800) 585-8887    Fax: (866) 585-8887

info@insuranceguys.com

 

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