Hagendoorn & Emond Insurance, Inc.

Life / Health Insurance Quote Form
For the fastest and most accurate life and/or 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!

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
  - -   M   F M   S     ft   in  lbs

Have you ever used tobacco in any form: Yes  No If yes, how long since you quit?

Have you 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):


Do you wish to include your Spouse on this coverage quote?     Yes     No


About Your Spouse (Only if he or she is to be covered):
Name Date of Birth Sex Occupation Height Weight
    - -   M   F     ft   in  lbs

Have you ever used tobacco in any form: Yes  No If yes, how long since you quit?

Have you 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):


Do you wish to include your child(ren) on this coverage quote?     Yes     No


Child # 1 (Only if he or she is to be covered):
Name Date of Birth Sex Occupation Height Weight
    - -   M   F     ft   in  lbs

Have you ever used tobacco in any form: Yes  No If yes, how long since you quit?

Have you 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):


Do you wish to include another child on this coverage quote?     Yes     No


Child # 2 (Only if he or she is to be covered):
Name Date of Birth Sex Occupation Height Weight
    - -   M   F     ft   in  lbs

Have you ever used tobacco in any form: Yes  No If yes, how long since you quit?

Have you 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):


Do you wish to include another child on this coverage quote?     Yes     No


Child # 3 (Only if he or she is to be covered):
Name Date of Birth Sex Occupation Height Weight
    - -   M   F     ft   in  lbs

Have you ever used tobacco in any form: Yes  No If yes, how long since you quit?

Have you 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):


Do you wish to include another child on this coverage quote?     Yes     No


Child # 4 (Only if he or she is to be covered):
Name Date of Birth Sex Occupation Height Weight
    - -   M   F     ft   in  lbs

Have you ever used tobacco in any form: Yes  No If yes, how long since you quit?

Have you 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):



Coverages

Please select the following coverages:
LIFE Coverages
Please select if interested in LIFE coverage.

Amount of Coverage (Self): $
Amount of Coverage (Spouse): $
Amount of Coverage (per child): $
Type of Coverage: Term
Whole
Universal

Disability Income
Monthly Amount:
 
Waiting Period:
Long Term Care Coverage
Monthly Amount:
 
Waiting Period:

Coverage for: Self
Spouse
Child #1
Child #2
Child #3
Child #4

HEALTH Coverages
Please select if interested in HEALTH coverage.

Amount of Deductible:
Co-payment plan:
Do you prefer
a PPO option?
Y   N
Maternity: Y   N
Preventative: Y   N
Coverage for: Self
Spouse
Child #1
Child #2
Child #3
Child #4

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!

Hagendoorn & Emond Insurance, Inc.

 

Home Auto Insurance Business Insurance  Home Insurance 
Life Insurance Other Insurance  Our Company Questions and Comments