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Life Insurance
General Questions
First Name:
Middle Name:
Last Name:
Gender:
How Did You Hear About Us:
Birth Date (mm/dd/yyyy):
Marital Status:
Email:
Confirmemail:
Address (where You Live):
City:
State:
Zip Code:
Home Phone No:
Cell Phone No:
Fax No:
LIFE INSURANCE COVERAGE
Amount Of Life Insurance Coverage?:
How Long Do You Need This Coverage For?:
Who Is The Policy For?:
Any Tobacco Usage In Last 12 Months:
Height:
Weight:
Medical Questions
Have you ever been treated for any of the following; Cancer, High Blood Pressure, Diabetes, Asthma, Immune System Disorders, Depression/Anxiety, Heart Disease, Drug/Alcohol Abuse, Epilepsy, or similar health conditions?  

Have any of your immediate family members (parents or siblings) had; cancer, heart disease, stroke or an aneurism prior to the age of 60?  

In the past three years have you been convicted of a DUI, or had a drivers license suspended / revoked?  

Are you a pilot?  

Are you currently on active military duty?  

Do you have a hazardous occupation?  

Do you have a hazardous hobby/avocation?  

Comment:


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Corporate Office
11201 Washington Blvd.
Whittier, CA 90606
Tel: (866) 999-9AIS
(562) 692 0506
Fax: (562) 695-6665
Email: accuraterateais@yahoo.com
Website: www.accuraterateais.com