Employee Benefits, Life Insurance, Critical Illness and Disability Insurance, Individual Health and Dental Plans

Individual Insurance

Completely fill out and submit this form to our agency to receive an accurate quote. You MUST provide at least one method of contact to receive a quote from our agency.

Amount of Coverage to be Quoted:
Type of Insurance policy:
How many years?:		Type of Policy:
Name:		E-Mail:
Street:		City:
Prov., Postal Code:		Daytime Phone:
Evening Phone:		Fax:
Personal Information
Sex`(required):`		DOB:
Height:	ft. in.	Weight:	lbs
Do you/have you smoked tobacco in the past 12 months?:
How much life insurance do you currently carry?
Have you ever had any indication of the following medical problems?
Heart disease:		Cancer:
HIV:		Diabetes:
Cholesterol:		High Blood Pressure:
Please explain 'Yes' answers from above and any medical problems you have had in the last 10 years:

If interested in a spouse, 2nd to Die or children's riders please give the following info
Spouse
Sex `(required):`
DOB `(required)`
Amount of coverage desired:
Please check that all information is correct. Thank you for your interest in the services Schmunk Gatt Smith & Associates have to offer. A representative will contact you shortly to discuss your options.