Kunevich & Lau Insurance Agency

Quote

Services
Automobile
Home Owners
Business
Life Insurance
Financial Services

Affiliations

 

Life Insurance Quote Request Form

 

General Information
Street:
City/State/Zip: / /
Home Phone: Work Phone:
Email Address:
Client Information

Name: (First, MI, Last)

Birth Date: Gender:(M)(F)  Height: Weight:
Home Phone:  Work Phone:
Best Time to Call: Morning Afternoon  Evening
Best Place to Call: Home Work
General Health Questions
In the past 36 months, has the person to be covered used any form of tobacco   Yes  No
In the past 60 months, has the person to be covered used any form of tobacco   Yes  No
Has the person to be covered ever been treated or sought treatment for diabetes, heart disease, cancer, or cardiovascular disease     Yes  No
Has the person to be covered ever sought treatment or been advised to seek treatment for the use of drugs or alcohol     Yes  No
Has the person to be covered ever been treated for depression     Yes  No
In the past 5 years, has the person to be covered been convicted of driving under the influence     Yes  No
In the past 3 years, has the person to be covered been convicted of 3 or more moving violations     Yes  No

         

 
 

All Forms Of Insurance

 

Website Designed & Maintained by David Magnell

Concept by Finerdesign.com