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Name:
Address:
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Phone Number:
Email Address:
#1
Insured's Name:
Date of Birth:
Date and time
Tobacco Use:
Select
Never
Quit < 12 months ago
Quit 1-5 years ago
Quit > 5 years ago
Currently smoke
Only cigars/pipe
Marijuana use
Amount of Insurance:
Sex:
Select
Male
Female
Health:
Select
Excellent
Good
Fair
Poor
#2
Insured's Name:
Date of Birth:
Date and time
Tobacco Use:
Select
Never
Quit < 12 months ago
Quit 1-5 years ago
Quit > 5 years ago
Currently smoke
Only cigars/pipe
Marijuana use
Amount of Insurance:
Sex:
Select
Male
Female
Health:
Select
Excellent
Good
Fair
Poor
Note:
Excellent
: trim/athletic, no medications
Good
: No infirmities, no medications
Fair
: Slightly overweight or taking medications
Poor
: Have or had a serious health condition
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We specialize in
RV insurance, Motorcycle, Antique Autos, Group Home and Auto Insurance
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