First Name: Last Name: Street Address:
City: State

Zip:
Email Address: Phone: Cell Phone

Gender: Household Income: Marital Status:
Number of kids Education  
 
Occupation    
   
What are the types of insurance do you own?
Life Health Home Owners Auto Motorcycle Dental
What kind of life insurance do you want?
Whole Variable Universal Universal Variable Don’t Know
What kind of life insurance do you currently have?
Whole Variable Universal Universal Variable Don’t Know
How much coverage to you need?
How much coverage to you have?
Here are some general health questions:
How do you rate your weight?
Do you have any pre-existing medical ailments like diabetes or cancer? Yes No
Has anyone in your family been diagnosed with cancer? Yes No
Do you or your spouse Smoke?  
Yes, I Smoke No, I Don’t Smoke Yes, my spouse Smokes I used to, but I don’t Smoke anymore
Are you currently covered by a Health Plan?
Which type of insurance plan do you currently have?
Which insurance carrier do you currently have?
If other, please enter carrier:
If you are covered under a health plan, do you have a vision benefit?
Yes No Yes, but is not very good
If you are covered under a health plan, do you have a dental benefit?
Yes No Yes, but is not very good
Does your company offer any supplemental health insurance?
Yes No
Does your company offer supplemental life insurance?
Yes No
Do you own or rent your dwelling?
Rent Own
Do you maintain insurance on your dwelling
homeowners rental insurance
Do you have adequate flood protection under your current policy?
Yes No Don’t Know
Are you shopping for auto insurance?
Yes No
How many vehicles do you insure?  
Year: Make: Model:
Year: Make: Model:
Year: Make: Model:
Year: Make: Model:
What kind of coverage do you maintain?
Do you insure anybody under the age of 21 in your household?
Yes No if yes, then [Age, Gender] of each        
        age gender age gender
        age gender age gender
How do you rate yourself as a driver?
Cautious Average Aggressive
Have you had any traffic violations in the last 2 years?
Yes No
Have you been convicted of a DUI (operation of a vehicle while intoxicated)?
Yes No


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