Insurance Supermarket

Life Questionaire

Fill out the information in each section as requested. Then at the end of the form supply your name and contact information, and submit the form. You will receive a quote from us shortly.

This survey is divided into the following sections:

Information about yourself Who's Covered Health Questions Form Submission

SECTION A -- Information about yourself

  1. Requested effective date?

  2. Amount of Life Insurance

    $50,000 $100,000 $300,000 $500,000$1,000,000 Other

  3.      Name    Telephone:
    Address   Email Add: 
             State   Zip 
  4. Reply by: Email  Mail  Phone  Fax
  5. How did you find us? Search Engine Referal Advertisment
  6. If search engine was used, which one?
  7. Date of Birth  Height'"  Weightlbs.
  8. Smoker Non-SmokerOther Tobacco Products
  9. Year of last Checkup
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SECTION B -- Information about your family:

  1. Are any of your dependents to be covered by this insurance?

  2. Dependents Information:
    Name: Relationship: Birthday: Sex
  3. Name: Relationship: Birthday: Sex
  4. Name: Relationship: Birthday: Sex
  5. Are any of the above Dependents overweight?YesNo
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SECTION C -- Health Questions

Explain all "Yes" answers.

  1. Do you or any dependents currently have life insurance coverage?YES NO
  2. Are you, your spouse or any dependent terminal or in nursing home?YES NO
  3. Within the last five years, have you or any dependent to be covered ever received any dedical or surgical consultation, advice, treatment, or medication for: YesNo

Cancer or Tumors
Heart Attack, Angina or other heart disorder
Excessive use of alcohol or alcoholism
Drug Abuse, dependence or addition
Nervous condition or disorder

Explain all YES answers:

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Thank you for taking the time to answer the questions in our questionaire.

Your quote will follow shortly.

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The Insurance Supermarket (800)700-3965
Revised: February 26, 2003.