Term Life Insurance for California CA Arizona AZ

LIFE INSURANCE

You Can Save up to 60% On Your Life Insurance!!

YOU ARE UNLIKELY TO FIND LOWER RATES ANYWHERE ELSE!!

Complete the form below as accurate as you can and we'll do the rest.

First Name

Last Name

Street Address

City

State

Zip Code

Day Phone

Evening Phone

Fax Number

E-mail Address

Best time to call:

Who is this quote for?

Gender

Birthday

Height

feet inches

Weight

lbs.

How much insurance
do you want?

What type of insurance
do you want?

Purpose of insurance:

Amount of insurance
in force now:

Current insurance carrier if known?

How much are you
currently paying per year?

Please indicate Tobacco/Nicotine Use:

If you used to smoke and have quit please indicate when.

Please list any medications
and dosage
(leave blank if none)

Have you ever been advised or treated for any of the following (Check all that apply)

AIDS Alcohol or Drugs Alzheimer's Disease Asthma Cancer Cholesterol Chronic Obstructive Pulmonary Disease Depression Diabetes	Heart Disease Hypertension Kidney or Liver Disease Mental Illness Stroke Ulcerative Colitis or Ileitis Vascular Disease Other

If you checked any of the above, please explain date of onset or beginning of treatment, diagnosis, and current status:

Are you a private pilot or student pilot?

Yes No

If yes, please explain type of rating, type of aircraft, total number of hours of experience, and number of hours flown per year (IFR, VFR, single-engine, multi-engine, etc.):

Do you engage in scuba diving, sky diving, rock climbing, motorized racing, or any other hazardous avocation or occupation?

Yes No

If yes, please explain.

Have you been convicted of drunk driving (past 5 years), or had 2 or more moving violations (past 3 years), or had your driver's license suspended or revoked (past 10 years)?

Yes No

If yes, please explain.

Have you ever been convicted of, or are you awaiting trial for a felony?

Yes No

If yes, please explain.

In the past 5 years, have you filed for bankruptcy?

Yes No

If yes, please explain including date of discharge.

Did any of the parents or siblings of the proposed insured have cardiovascular disease or cancer, prior to age 60?

Yes No

If yes, please explain.

Are you a United States citizen:

If no, what country?

IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent. Also, in no way does submission of this form obligate anyone to any contract.

Insurance Guys is a registered trademark of Carney & Mishkin Insurance and Financial Services, Inc.
California Insurance Lic. #0B53906
Steve Carney & Greg Mishkin are owners of InsuranceGuys Insurance Services.
Steve Carney , Registered Principal, and Greg Mishkin, Registered Representative, offer securities through Sentra Securities Corporation, a Registered Broker Dealer. Member: NASD, SIPC.
Branch Office: 637 Juanita Ave., Santa Barbara, CA 93109

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