Life/Health Quote Form
For the fastest and most accurate life/health insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used
for quote purposes ONLY!
Please fill in the blanks using your computer, then print (press Control-P or Print from the File menu)
and fax this form to:
Highland: 618.654.3826 or Greenville: 618.664.1858 or Edwardsville: 618.656.8528.
Thanks from SIUA, Inc.
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General Information
Name:
Address:
City:   State: ZIP:
County:   Email:
Phone Day: ( ) -            Night: ( ) -
Best time to call:   AM   PM

About Yourself:
Date of Birth Sex  Marital Status  Occupation Height Weight Do you smoke?
 --  M   F M   S     ft   in  lbs Y   N

Have you have had any of the following health conditions: Heart     Cancer     Diabetes    
HBP

Are you currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list:

Please DISCLOSE any and all health conditions you have (or had in the past):

Dependents Information

Name

Date of Birth

Sex

Smoker

Relationship
M   F Y   N
M   F Y   N
M   F Y   N
M   F Y   N
M   F Y   N
M   F Y   N
M   F Y   N


Coverages

Please select the following coverages:
LIFE Coverages

Please select if interested in LIFE coverage.

Amount of Coverage (self): $
Amount of Coverage (dependent): $
Type of Coverage: Term 5 years
Term 10 years
Term 15 years
Term 20 years
Permanent Insurance? Y   N
Disability Income Insurance
    Income Protection
    Monthly benefit requirement:		 $
Long Term Care Ins.
    Convalescent Care
    Daily benefit amount:		 $

HEALTH Coverages

Please select if interested in HEALTH coverage.

Family/Individual Health Insurance
Medical Savings Accounts

Deductible

Current insurance coverage description:
Would you like Information about
Annuities/Retirement Planning?		 Y   N

Additional Comments:
Please give any additional comments about the coverage you desire:

Thank you for your time in submitting this Life / Heath quote form. One of our representatives will respond to your submission as soon as possible!

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