Misc Quote

Quote for Miscellaneous Risk

Please complete the following information so you can get a customized quote .

General Purpose Questionnaire

	Name
	Address

	Phone
	Fax
	E-Mail

Client Information

	Date of birth	mm dd yy
	Sex	M F
	Height
	Weight (lbs.)
	Smoker	Yes No
		(if yes, also complete tobacco questionnaire)
	Insurance amount
	Insurance type
	Additional insured's name (only if applying for Survivor UL)

Other company(s) actions
	Date applied	mm yy
	Company
	Declined
	Postponed
	Rated table

1. What is client's illness?

	please provide details
2. When was diagnosis made?
	mm yy
3. What type of treatment has been received?
	surgery month/year
	medication (list)
	other types of treatment
4. When was last visit to a physician about this disorder?

5. Date and result of last cholesterol reading.
	mm yy
6. Date and result of last blood pressure reading.
	mm yy
7. How many times per week does client exercise?

	Type of exercise
8. Are there any other illnesses/impairments?

9. What medication is currently being taken?

10. Has either parent, or any sibling, died before age 65, other than by accident?
	Yes No (If yes, list relationship(s) and cause)
	cause
	cause
	cause
Additional Information