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Term Life Insurance for Individuals with Health Impairments

ASK THE DOCTOR
QUICK QUOTE FOR
DRIVING VIOLATIONS

INFORMATION GATHERED WILL BE USED IN THE EVALUATION OF THE INSURABILITY OF THE APPLICANT. OFFERS ARE TENTATIVE AND ARE SUBJECT TO VERIFICATION OF THE SUBMITTED MEDICAL EVIDENCE AND OTHER CRITERIA USED IN THE UNDERWRITING OF LIFE INSURANCE.© COPYRIGHT E-DIRECT INSURANCE


* Required Information

Applicant Information
* Applicant's Name:
* Date Of Birth:
00/00/0000
* Gender:
Male Female
* Height:
ft/in
* Weight:
lbs
* Occupation:
* Death Benefit:
* Type of Product:
Term Universal Whole Life
Second to Die Variable
Tobacco Use: Yes No
Type:
Replacement: Yes No
Current Ann. Premium $
Last Life Insurance Application Year
Company
Action
1. List all moving motor vehicle and speeding violations over the past five years: Month Year
Month Year
Month Year
Month Year
Month Year
Month Year

2. Does the client currently hold a valid
driver's license?

Yes No
State Exp Date
3. Detail last moving violations other than speeding if any:

Month Year
Type
Month Year
Type

None

4. Detail accidents involving major property damage, if any: Month Year
Details
Month Year
Details
5. Within the last 6 years, list the occasion and date of driving under the influence (DUI) arrests and convictions: Month Year
Month Year
Month Year
Month Year

None
6. Has the client ever been treated for substance abuse? No Yes, please detail:
Month Year
7. List any other illnesses or impairments (complete any other quick quote forms that may apply). Along with all meds and vitamins taken, include dosage and frequency:
Please fill out all information completely and accurately.

 
E-DIRECT INSURANCE.
11/ 01/ 2005
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