E-mail Address:              

Your Name:                   

Date of birth (DD/MM/YY):    

Sex:             Male    Female  

Height: cm. Weight: Kilos

Tobacco Use:                 
(Please Select)
Have never smoked or used nicotine
Quit less then 1 year ago
Quit 1-3 years ago
Quit 3-5 years ago
Quit more then 5 years ago
Currently smoke cigarettes
Other nicotine use: cigars/pipe/chew/patch


Health Status:               
(Please Select)
Excellent: Trim and athletic, no medications
Good: No infirmities and no medications
Fair: Slightly overweight or taking medications
Poor: Have/had a serious health condition


Health Conditions?         
Yes    No        Explain: 

Prescription Medications?   
Yes    No        Explain: 

Do you engage in any hazardous activities?   
Yes    No        Explain: 

Did your parents or siblings have heart disease or cancer prior to age 60??   
Yes    No        Explain: 

Amount of Insurance:         
(Please Select)
$10,000
$20,000
$25,000
$50,000
$75,000
$100,000
$125,000
$500,000
$1,000,000
More then $1,000,000


How would you like to receive your quote?
Email:     Fax:   If reply by fax - Fax Number: 

Alternate quote requests (please specify):  

All comments and suggestions appreciated!