Life Insurance Quote - Fleetwood Insurance Group

Quote Request for Life Insurance

Please complete and submit the form below to receive a quote. While not all fields are mandatory, providing this information will help us offer you a more accurate quote.

1.) Personal Information

Name

Phone

Address

Social Security Number

Date of Birth

Weight

Height

Occupation

2.) Requested Coverage

Proposed Amount of Insurance

Purpose of Insurance

Plan

Please Provide Details on In Force Coverage

Company

Policy Date

Amount

Current Premium

Do you intend to replace?

Do you have any other pending or anticipated applications for life insurance?

Have you had any life insurance applications declined, rated, postponed, withdrawn, modified, cancelled, or not renewed?

If Yes, List Date & Reason

3.) Personal History

Do you currently drive?

Driver's License Number

Driver's License Expiration Date

Any moving violation in last 3 years?

Have you ever had your license suspended, restricted or revoked?

Have you ever been convicted of a DWI/DUI?

If Yes, Date of DWI/DUI

Did you lose or gain more than 10 pounds in the past year?

If Yes, Explain Reason For Weight Changes

Do you engage in regular exercise?

If Yes, Times Per Week/How Long Per Occasion

Do you intend to reside or travel outside of the United States within the next two years?

If Yes, Provide City, Country, Dates/Duration and Purpose of All Travel

4.) Tobacco Use

Have you ever used any form of tobacco or nicotine products?

If yes, are you a current user?

If no, date of last use?

If yes, what type?

If yes, quantity of use?

5.) Medical History

Who Is Your Primary Care Physician?

When Did You Last Consult Him/Her?

What Other Physician Have You Consulted During The Past 3 Years and Why?

In What Hospitals, Clinics, or Other Facilities Have You Ever Been Treated?

List All Current Medications, Including Over The Counter Drugs & Vitamins

Have You Been Diagnosed With Coronary Disease?

Have You Been Diagnosed With Any Form of Cancer?

If Yes, Type/Location and Stage

Have You Been Diagnosed With Diabetes?

What Is Your Diabetes Treatment?

Have You Ever Had Any of The Following: Eye Trouble, Kidney Trouble, Heart Trouble, Neuritis/Neuralgia, High Blood Pressure or Insulin Reaction?

If Yes, Please Provide Details

6.) Family History

Have Your Immediate Family Members (Parents, Siblings) Been Diagnosed Or Died From Heart Disease Or Cancer?

Provide Details-Including Relation, Diagnosis, Approx. Age of Disease Onset & If Deceased, Age at Death

7.) Drug & Alcohol Use

Do You Currently Drink Alcohol?

If Yes, Amount Per Week, Type Of Alcohol (ie, Beer, Wine, Liquor)

Have You Ever Used Illegal Drugs Or Sought Treatment Because Of Drugs Use?

If Yes, Provide Details

8.) Activities

Are You a Private Pilot?

Please note that coverage is not bound or altered unless confirmation is received from an agent. You also agree to release us from any liability if this information is accidentally viewed by unauthorized others. We will only use this information for insurance quoting purposes.