promarkny.files.wordpress.com€¦ · Web viewAdditional Medical History and Medications (Please...
Transcript of promarkny.files.wordpress.com€¦ · Web viewAdditional Medical History and Medications (Please...
Please print, fill and fax to: (585) 424-3647Phone: 535-424-4330 gina@promarkny,comLife Insurance Proposal Request
Agent Name: ____________________________________ Phone Number: ___________
Client Name: ____________________________________ Date of Birth: _____________
Spouse Name: ___________________________________ Date of Birth: _____________
Product Requested:
Term InsurancePurpose of Insurance:
Duration:
Face Value: Guaranteed Face Amount/Premium
Yes No
Alternate Money: Riders:Waiver of Premium
YesNoAD&D
Medical History: Circle those that apply
Client Tobacco Stroke Diabetes Cancer Heart DiseaseSpouse Tobacco Stroke Diabetes Cancer Heart Disease
Additional Medical History and Medications (Please indicate Client (c) or Spouse (s)):
Both Applying?
Permanent Insurance Universal LifePurpose of Insurance:
Duration:
Face Value: Guaranteed Face Amount/Premium Yes No
Alternate Money: Riders:Waiver of Premium
YesNoAD&D
Immediate Family History—Death before age 60? Cause of Death: