Term Life Questionnaire

*Name:
House Address:  
City:
State: Zip Code: 
*Home Phone: ( )- -
Work Phone: ( )- -
Fax: ( )- -
*Email:
Present Insurance Carrier:


What is your date of birth?
please use mm/dd/yyyy format
 
Have you used any nicotine products in the last 6 years?
 
If yes, please give details...ie type of product (cigarette, cigar, chew, pipe), amount used, length of use, last used:
   
What is your weight?
What is your height?
   
Are you on any medications and if so, why are you taking them?
 
Have you ever had, or do you now have, any of the following:
Cancer
HIV
Hepatitis
Heart Problems
Stroke
Mental Health Problems
Alcoholism
DUI
Diabetes
Other Serious Disease
  If Other Serious Disease, please explain:
  Please provide details (date of diagnosis, treatment, last date of treatment, ect.);
 
Has any of your immediate family (siblings, mother, father) passed away prior to age 60?
 
If so, was it due to cancer heart disease, or stroke?
 
Has any living member of your family had cancer, heart problems, stroke or diabetes prior to age 60?
 
Have you ever been rated or declined for insurance?
If so, please provide details:
 
Do you participate in any special activities (aviation, scuba, rock climbing, motorcycle racing, ect) recently traveled to a foreign country, or have plans to do so?
 
How many moving violations do you have in the past 3 years:
Please provide details:


Before you submit it is recommended that you print out a copy of this form for your records.This information will be submitted directly to Horton Personal Insurance personnel.  We will handle your personal information in a confidential manner throughout the quoting process.

*required fields