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Tobacco Use
Quote Request Form
Client Information
Name
*
Address
City, State, Zip
*
Day Phone
*
Evening Phone
Cell
Phone
Fax
Email
*
Date of birth
mm
dd
yy
*
Sex
M
F
*
Height
Feet
2 '
3 '
4 '
5 '
6 '
7 '
8 '
9 '
Inches
0"
1"
2"
3"
4"
5"
6"
7"
8"
9"
10"
11"
*
Weight (lbs.)
*
Smoker
Yes
No
*
Insurance amount
1
Insurance type
Select one
Term
UL
Survivor UL
Additional
insured's name
(only if applying
for Survivor UL)
Other company(s) actions
Date applied
mm
yy
Company
Declined
Postponed
Rated table
1. In the past 12 months, client has used tobacco products as follows
Cigarettes
quantity
select one
per day
per week
per month
Cigars
quantity
select one
per day
per week
per month
Pipe
quantity
select one
per day
per week
per month
Chewing
quantity
select one
per day
per week
per month
Smokeless
quantity
select one
per day
per week
per month
2. In the past 24 months, client's use of tobacco products has changed as follows
3. Has client used the noted tobacco products regularly at any time during their life?
Yes
No
If yes, describe regular usage per day, week or month and the number of years each tobacco product was used on a regular basis
4. Is client currently using a nicotine patch or any other nicotine products to help stop smoking?
Yes
No
if yes, describe
Additional Information
Submit
* Required
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