Robert C Benner Insurance, LLC.

Get a Quote - Health / Life Insurance

Policy Holder
Client Name*:
Date of Birth*:
Email:
Phone Number:
Gender: Male
Female
Coverage
Coverage Amount:
Term: 10
15
20
25
30
ROP
UL
WL
IUL
VUL
Rate Class Requirements: Best Class
Preferred
Std Plus
Standard
Other
If Other, please explain:
Lifestyle
Have you used any nicotine-based products in the past?: 12 months
24 months
36 months
Not at all
If so, type & frequency?:
Have you had more than 2 moving violations in the past 3 years, or any DUIs?: Yes
No
Has either parent or a sibling has a history of heart disease or cancer?: Yes
No
Has either parent died prior to age 60 from heart disease or cancer?: Yes
No
Have you been diagnosed and treated for heart disease, diabetes, or cancer (including skin cancer)?: Yes
No
Any other medical conditions?:
Do you take any medications? If so, type & reason?:
Height:
Weight:
Foreign Travel: Have you travelled or intend to travel overseas? If yes, where and how long?:
Avocations: Do you have any hobbies like aviation, scuba diving, race car driving, etc?:
Any other life insurance? If so, type & amount?:
Competitive or Replacement sale?: Yes
No
Comments / Explanations / Other Requests:
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