Duncan & Associates - Products & Services - Life/Individual Medical Insurance Quote Request Form

DUNCAN & ASSOCIATES
LIFE/INDIVIDUAL MEDICAL INSURANCE QUOTE REQUEST FORM

1. Client's Name:	Male/Female:	Date of Birth/Age:

2. Height:	Weight:

3. ANY tobacco used (please indicate type and amount)? In the last 12 months: In the last 24 months: In the last 36 months: In the last 60 months:

4. Any family history of cancer or heart problems (please explain)?

5. Do you take any medications (please explain)?

6. Have you had any medical condition(s) in the last 10 years? If so, please explain.

LIFE INSURANCE

Quote amount options: $ $ $

Type of Policy

Level Term: (check all that are desired)

5 10 15 20 30 All Durations

Universal Life Second-To-Die Lifetime Guarantee Premium
Minimum Premium Limited Pay Years

Whole Life:

Current Life Insurance in Force:

Amount
Company