Life and Health
Insurance Form		 This is a free, no obligation  insurance quote. 

Please provide as much information as possible for the best price quote . 

Personal Information

Name:

Address:

City:

  State: Zip:

Home Phone#:

   Work Phone#:

When To Call: 8am etc 

  Cell Phone#

Email Address

Occupation:
About Yourself:
Date of Birth Sex  Marital Status  Occupation Height Weight Do you smoke?
  M   F M   S     ft  
in 		 lbs Y   N
Have you have had any of the following health conditions:
Heart     Cancer     Diabetes     HBP
About Your Spouse (Only if he or she is to be covered):
Date of Birth Sex Occupation Height Weight Do they smoke?
  M   F     ft       in  lbs Y   N
Child #1(Only if he or she is to be covered):
Date of Birth Sex Occupation Height Weight Do they smoke?
  M   F     ft  
in 		 lbs Y   N
Child #2(Only if he or she is to be covered):
Date of Birth Sex Occupation Height Weight Do they smoke?
  M   F     ft  
in 		 lbs Y   N
Child #3(Only if he or she is to be covered):
Date of Birth Sex Occupation Height Weight Do they smoke?
  M   F     ft  
in 		 lbs Y   N
Please select coverages:

Life Coverages:

Amount of Coverage (self): $
Amount of Coverage (spouse): $
Amount of Coverage (per child): $
Type of Coverage: Term
Whole
Universal
Disability Income Coverage? Y   N
Long term care coverage?   Y   N
Coverage for: Self
Spouse
Child #1
Child #2
Child #3

 

Health Coverages
Please select if interested in HEALTH coverage.

 

High deductible
catastrophic plan:		 Y   N
No deductible co-pays: Y   N
Maternity: Y   N
Mental Health: Y   N
Chiropractic: Y   N
Acupuncture: Y   N
Dental: Y   N
Vision: Y   N
Preventative: Y   N
Coverage for: Self
Spouse
Child #1
Child #2
Child #3
 
 
 
 


Copyright © 2006 | Collins & Miller Insurance LLC | all rights reserved
 Disclaimer: This material is for informational purposes only and is not a contract. It is intended to provide a general description of products and services. Please remember that only an insurance policy or contract can give actual terms, coverage's, amounts, conditions and exclusions. For complete descriptions of the terms, conditions and exclusions of insurance coverage's or other products or services, please contact your independent agent or refer to the policy or service contract.
Licensed in the following states: Tennessee