Lee County Inside

Personal Life Quote
This form is a request for PERSONAL LIFE insurance coverage. Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.

Full Name:
E-Mail:
Phone:
State residence: Birth Date:	/ /
Height: Weight: Gender:	feet inches pounds Male Female
When did you last use any type of tobacco products?

Have you been treated or taken medication for any of the following conditions within the past 10 years:	Asthma Cancer Blood Disorder Drug Abuse Disorder of Intestines	High Blood Pressure Depression Alcoholism Heart Disease Disorder of Kidneys, Bladder, or Prostate
	Arthritis:
	Thyroid
	Diabetes
	Other Conditions:
The following information can help us provide you with the most accurate quote.
Is your Blood Pressure above 140/85?	Yes No Don't know
What is your Cholesterol Count?
Have you been a pilot or airline crew member in the past 3 years?
Have you had more than 3 moving traffic violations in the past 3 years?
Have you ever been convicted of a DUI?
Before the age of 60, has anyone in your immediate family (siblings and parents) been diagnosed with cancer, diabetes, or heart or kidney disease? No Yes
Insurance Needs
	Select the amount of insurance needed for this quote.
Check the term(s) to be quoted	(the number of years you need the insurance to be in effect) 5 10 15 20 30
Payment Mode:	(Note that insurance carriers will typically charge a nominal surcharge for the Quarterly or Semi-annual Payment Modes) Monthly Quarterly Semi-Annual Annual

390 Pondella Road Suite 1 * North Ft. Myers, FL 33903 * Phone: 239.656.5551 * Fax: 239.656.0640

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