LIFE Insurance Quote - Greater Insurance Service, Independent Insurance Agency, Insurance

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LIFE INSURANCE QUOTE

WE PROVIDE INSURANCE COVERAGE FOR MINNESOTA ONLY
To obtain a FREE, no obligation quote for Life insurance, fill out the form below and we will contact you. If you prefer to give information over the phone, fill out the * areas only and we will give you a call, or print this out and mail or fax it to us.

Name:

Address:

City:

State:

ZIP:

Home Phone:

Email:

Work Phone:

Cell Phone:

Date of Birth

Height:    Weight:

Do you use tobacco in any form: Yes   No

Cigarettes: Yes   No     Cigars or Pipes: Yes   No     Chewing Tobacco: Yes   No

Type of coverage desired: Term Life   Permanent Insurance

Coverage level desired:

100,000
250,000
500,000
1 Million
Higher Level

Are any specific riders to be included in the quote?
    Waiver of premium
         (makes your life insurance premium payment for you if you become totally disabled)
    Children's term rider (provides limited levels of coverage for your children)
    Accidental death (provided higher level of coverage if you die in an accident)

If you have selected term coverage how long do you want the rates to remain level?
   5 years   10 years   15 years   20 years

The following questions are what you will see on most health and life insurance applications. Please be prepared to explain a yes response to any of these questions. For quote purposes simply check yes or no for each question. In the last 10 years have you or your dependents had or been treated for:
Diabetes or sugar, protein, or blood in the urine?	Yes No
High blood pressure, chest pain, heart murmur, shortness of breath, angina, or other heart, blood or circulatory disorder?	Yes No
Stroke, multiple sclerosis, cerebral palsy, seizures, headaches or any disorder of the brain or nervous system?	Yes No
Asthma, allergies, emphysema, lung or respiratory disorder?	Yes No
Digestive disorder, ulcer, hepatitis, or any disorder of gallbladder, liver, stomach or intestines?	Yes No
Varicose veins, skin ulcerations, phlebitis, or hernia of any kind?	Yes No
Kidney, bladder, prostate or urinary disorder?	Yes No
Disorder of breast or reproductive organs (male or female), infertility, or abnormal menstrual period?	Yes No
Rheumatoid arthritis, osteoarthritis, TMJ, or any disorder of the joints, muscles, back or bones?	Yes No
Cancer, tumor, cyst, or growth of any kind?	Yes No
Been diagnosed as having or been treated for any immune deficiency disorder by a member of the medical profession?	Yes No
Experienced any of the following: Signs and symptoms of an immune deficiency disorder may include lymphadenopathy (swollen lymph nodes), loss of appetite, weight loss, chronic fatigue, fever, oral thrush, skin rashes, unexplained infections, dementia, depression, or other psychoneurotic disorders with no known cause?	Yes No
Been treated for alcohol or drug abuse or joined any programs for alcoholism or drug abuse?	Yes No
Been seen for psychological disorders, anxiety, eating disorder or had professional counseling?	Yes No
Had any medical treatment, health, mental or physical impairment, surgery or congenital disorder, not mentioned above?	Yes No
Does any person have any fixation/prosthetic devices present including but not limited to plates, screws, pins, implants (including breast implants), shunts, pacemakers or valve replacements?	Yes No
Had a medical examination, electrocardiogram, X-ray, blood test, or diagnostic test?	Yes No
Is anyone currently receiving disability for worker's compensation or payments from an auto carrier for any injury?	Yes No
Is anyone currently disabled, hospitalized or on medical leave?	Yes No
Is anyone currently pregnant?	Yes No
Has anyone proposed for coverage ever been declined, or rated for life, disability, or medical insurance?	Yes No
Have any of the proposed insured's ever participated in organized racing including but not limited to, automobile, motorcycle or power boat racing or any of the following activities: skydiving, ultralight flying, scuba diving, hang gliding, rock or mountain climbing?	Yes No
Have any of the proposed insured's been cited for DWI in the past 5 years or had 2 or more moving violations in the past 2 years?	Yes No

Additional comments including any major health problems
you may have encountered in your lifetime or if you
answered YES to any questions above: